Supreme Court of the State of New York Appellate Division: Second Judicial Department AFFIDAVIT CHANGE OF ATTORNEY NAME State of _________________ ) County of ______________________________) s.s.: _________________________________________________________, deposes and says that: being duly sworn, 1. I was admitted to the practice of law by the Appellate Division, Second Department, on ________________, under the name of __________________________________________. 2. I now seek permission to change the name under which I practice law to ________________________________________________. 3. I have not been known by any other names. (strike one) I have been known by the following other names: 4. I seek to change the name under which I practice law for the following reason: ____ ____ My name has been changed by court order pursuant to Civil Rights Law � 63 (attach a certified copy of the court order authorizing the name change). My surname has changed by reason of marriage pursuant to Domestic Relations Law �� 14 and 15(1)(b) and Civil Rights Law � 65(1) (attach a certified copy of your certificate of marriage registration setting forth your changed marital surname). My surname has changed by reason of a divorce or an annulment of a marriage pursuant to Domestic Relations Law � 240-a and Civil Rights Law � 65(2) (attach a certified copy of your judgment of divorce or annulment authorizing the resumption of use of a surname by which you were known prior to marriage). ____ 5. I am in good standing at the bar, in that I am not disbarred or suspended from practice, I am duly registered with the Office of Court Administration, and I am current in the payment of the biennial registration fee. American LegalNet, Inc. www.FormsWorkFlow.com 6. I am not currently subject to a pending disciplinary investigation and to my knowledge there are no complaints of professional misconduct filed against me. 7. No previous application to change the name under which I practice law has been made (except as follows). WHEREFORE I request that the name under which I am authorized to practice law as recorded on the Roll of Attorneys and Counselors-at-Law on file in the office of the Clerk of this court be changed as set forth above. Dated: ___________________ ____, 20___ ___________________________________ Signature Sworn to before me this ________ day of _____________________, 20___ __________________________________ Street Address __________________________________ City, State, Zip __________________________________ Phone Number _________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com