________________ Court of the State of New York County of ________________ In the Matter of the Application of __________________________, as Parent For Leave to Change the Name of the Child ____________________________________ to ____________________________________ ORDER GRANTING LEAVE TO CHANGE CHILD'S NAME Index #: _________________ Upon the annexed Petition of ________________________________________, verified on __________________________, requesting for a change of name of the child _____________________________ to ___________________________ and the Court being satisfied that the Petition is true, and it appearing from the Petition and the Court being satisfied that there is no reasonable objection to the change of name proposed, it is hereby ORDERED that, 1. The individual currently known as _________________________________ who was born on ___________________________ at ______________________________ (with birth certificate number __________________, issued by the Department of Health of _______________) (with __________________________ as proof of birth, since no birth certificate is available) is hereby authorized to assume the name of _________________________________ in place and stead of the present name upon complying with the provisions of Article 6 of the Civil Rights Law and of this Order. 2. This Order shall be entered and the Petition upon which it was granted shall be filed prior to the publication directed below in the office of the County Clerk of _______________________ County. 3. At least once within sixty days after the making of this Order, a notice shall be published in ____________________________________, a designated newspaper in _______________________ County, in substantially the following form: Notice is hereby given that an order entered by the Supreme Court, _______________________ County, on the ________ day of American LegalNet, Inc. www.FormsWorkFlow.com ____________________, bearing Index Number __________________, a copy of which may be examined at the office of the clerk, located at __________________________________________________, grants me the right to assume the name of _________________________________. The city and state of my present address are _____________________________; the month and year of my birth are __________________________; the place of my birth is _______________________________________; my present name is ___________________________________. 4. Within ninety days of the making of this Order proof of such publication by Affidavit shall be filed with the County Clerk of _______________________ County. 5. Following full compliance with the provisions of this Order, the child _________________________________ shall be known as and shall be authorized to assume the name _________________________________. ENTER: ________________________________ J.S.C. American LegalNet, Inc. www.FormsWorkFlow.com