THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) NAME CHANGE AFFIRMATION A. I affirm that I am not a person who, or the person whose name I seek to change is not a person who: 1. has been convicted in any court of a crime punishable by imprisonment for a term exceeding one year; 2. is a fugitive from justice; 3. is an unlawful user of or addicted to any controlled substance, as defined in the Controlled Substances Act, 21 U.S.C. 802; 4. has been adjudicated as a mental defective or who has been committed to a mental institution; 5. being an alien a) is illegally or unlawfully in the United States; or b) except as provided in 18 U.S.C 922(y)(2), has been admitted to the United States under a nonimmigrant visa, as that term is defined in the Immigration and Nationality Act, 8 U.S.C. 1101(a)(26); 6. has been discharged from the Armed Forces under dishonorable conditions; 7. having been a citizen of the United States, has renounced his citizenship; 8. is subject to a court order that a) was issued after a hearing of which such person received actual notice, and at which such person had an opportunity to participate; b) restrains such person from harassing, stalking, or threatening an intimate partner of such person or child of such intimate partner or person, or engaging in other conduct that would place an intimate partner in reasonable fear of bodily injury to the partner or child; and c) (i) includes a finding that such person represents a credible threat to the physical safety of such intimate partner or child; or (ii) by its terms explicitly prohibits the use, attempted use, or threatened use of physical force against such intimate partner or child that would reasonably be expected to cause bodily injury; or 9. has been convicted in any court of a misdemeanor crime of domestic violence. B. One or more of the above paragraphs do apply to me, or to the person whose name I am seeking to change, as follows: (List the paragraph # from above, and write any details that would explain to the court why your petition for change of name should be granted notwithstanding. Attach additional sheets if necessary.) Date Signature of Petitioner State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any NHJB-2320-F (10/30/2006) , County of by Signature of Notarial Officer / Title Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com