Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Affidavit Re Change Of Name Form. This is a Connecticut form and can be use in Probate Statewide.
Loading PDF...
Tags: Affidavit Re Change Of Name, PC-910, Connecticut Statewide, Probate
STATE OF CONNECTICUT
AFFIDAVIT RE
CHANGE OF NAME
PC-910 REV. 7/12
RECORDED:
COURT OF PROBATE
[To be submitted with form PC-901, Application for Change of Name (Adult)]
[Type or print in black ink. Complete Confidential Information Sheet for PC-910 on next page.]
TO: COURT OF PROBATE,
DISTRICT NO.
IN RE CHANGE OF NAME OF:
The subscriber, being duly sworn, hereby swears, affirms, or avers that:
1. I presently live at:
and have been a resident of
2. I
Connecticut for
years.
Do not own real estate located in
Do
3. I do not have any outstanding debts that are in arrears. I will notify my creditors of the change of name.
4. A.
I have never been convicted of any offense.
B.
I have been convicted of a minor offense.
C.
I have been convicted of a criminal offense, as described below.
Due to the nature of my offense, I am obligated to register on the Sex Offender Registry, and, prior to
filing this application with the court, I have notified the Commissioner of Public Safety in accordance
with C.G.S. ยง 45a-99.
5. The purpose of the change of name is not to deceive, defraud, or mislead any person or governmental agency, nor to avoid the legal
consequences of a criminal conviction.
6. I
have
have not applied for a change of name previously in either probate court or superior court.
Court name and address:
Affiant ......................................................................................................
Date: ...............................................................................
Tel. No.
SUBSCRIBED AND SWORN TO
BEFORE ME
DATE
.....................................................................................
Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct.
AFFIDAVIT RE CHANGE OF NAME
PC-910
American LegalNet, Inc.
www.FormsWorkFlow.com
CONFIDENTIAL
STATE OF CONNECTICUT
DO NOT RECORD
INFORMATION SHEET
FOR PC-910, Affidavit Re:
COURT OF PROBATE
[Type or Print in Black Ink.]
Change of Name
NEW 7/12
_____________________________________________________________________________________
Court of Probate, ______________________________________________ District
The social security number of the subscriber/affiant is required in connection with this proceeding
for change of name:
Subscriber/Affiant: __________________________________________________________________
Social Security Number:____________________________________________________
American LegalNet, Inc.
www.FormsWorkFlow.com
