SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________________________ In the Matter of the Application of ________________________________ ORDER INDEX #______________ for leave to Change His/Her Name to _________________________________ ______________________________________________ Upon the petition of __________________________verified the _________ day of ______________, 20_____, seeking leave to change his/her name from___________ _______________________to __________________________________, and the court being satisfied thereby that the petition is true and that there is no reasonable objection to the change of name proposed, Now, on motion of ______________________________, it is ORDERED, that the petitioner, _____________________________________, born on ___________________, 19_____, at _______________________, New York, County of ________________________, whose birth certificate number is _____________________ is hereby authorized to assume the name __________________________________________ in place of his/her present name upon compliance with the provisions of this order, and it is further ORDERED, that this order shall be entered and the papers on which it was granted filed, prior to the publication hereinafter ordered, in the office of the Clerk of the County of ________________ wherein petitioner resides, and it is further ORDERED, that at least once within twenty days after entry of this order, a notice shall be published in the _______________________, substantially in the form prescribed by American LegalNet, Inc. www.USCourtForms.com ORDER PAGE -2- Section 63 of the New York Civil Rights Law. (SEE BELOW) Notice is hereby given that an order entered by the _____________court, ___________ county , on the ________________day of ______________, bearing Index Number ____________ , copy of which may be examined at the office of the clerk, located at ________________________ __________________, in room number__________grants me the right, effective on the _________ day of ________________, to assume the name of _______________________________. My present address is _________________________________________________; the date of my birth is ________________________; the place of my birth is ____________________________________; _________________________________; my present name is________________________________. ORDERED, that within forty days of the making of this order, an affidavit of publication as of the aforesaid notice shall be filed in the office of the Clerk of the County of __________________ , and it is further ORDERED, that upon full compliance with the above provisions of this order, the petitioner shall be known by the name________________________________, which he/ she is hereby authorized to assume and by no other name. ENTER DATED: _______________ , New York _______________, 20_____ _____________________________________ J. S. C. American LegalNet, Inc. www.USCourtForms.com