APPLICATION FOR CHANGE OF NAME (ADULT) PC-901 REV. 7/12 RECORDED: STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] [Attach PC-910, Affidavit Re Change of Name.] Complete Confidential Information Sheet for PC-901 on next page.] TO: COURT OF PROBATE, IN RE CHANGE OF NAME OF PETITIONER [Give present name and new name as requested.] NAME: First CHANGED TO: First DATE OF BIRTH AND PLACE OF BIRTH: NAME ON BIRTH CERTIFICATE: PRESENT ADDRESS/ TEL. NO.: HOW LONG HAS PETITIONER LIVED THERE? NAME AND ADDRESS OF NON-PETITIONING SPOUSE, IF ANY: SPOUSE CO-PETITIONER [Give present name and new name as requested.] NAME: First CHANGED TO: First DATE OF BIRTH AND PLACE OF BIRTH: NAME ON BIRTH CERTIFICATE: PRESENT ADDRESS/ TEL. NO.: HOW LONG HAS CO-PETITIONER LIVED THERE? A change of name is sought for the following reasons: Middle Middle Middle Middle DISTRICT NO. DATE OF APPLICATION Last Last Last Last The petitioner(s) represent(s) that the purpose of seeking a 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, but solely for the reason(s) stated above. WHEREFORE, the petitioner(s) as indicated above, request(s) a change of name to the name(s) stated above. The representations contained herein are made under the penalties of false statement. SIGNED: PETITIONER............................................................................................... CO-PETITIONER ...................................................................................................... APPLICATION FOR CHANGE OF NAME (ADULT) PC-901 Date: Date: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION/ Petition for Change of Name (Adult) PC-901C NEW 10/16 CONNECTICUT PROBATE COURTS DO NOT RECORD ­ FOR COURT USE ONLY RECEIVED: Probate Court Name In the Matter of District Number , a minor child. The social security numbers of the following parties are required in connection with this proceeding for change of name: 1) Petitioner: Name _____________________________________________________________________________________ Social Security Number _______________________________________________________________________ 2) Spouse/Co-Petitioner: Name _____________________________________________________________________________________ Social Security Number _______________________________________________________________________ _______________________________________________________________________________________________ Confidential Information/Petition for Change of Name (Adult) PC-901C American LegalNet, Inc. www.FormsWorkFlow.com