At a term of the Supreme Court of the State of New York, held in and for the County of _______________________, at _______________________, NY on ______________________, 20______. Present: Hon..______________________________ Justice of the Supreme Court In the Matter of the Application of ________________________________ For Leave to Assume the Name of ________________________________ ORDER GRANTING LEAVE TO CHANGE NAME Index #: _________________ Upon reading and filing of the petition of ________________________________ verified the ______ day of __________________, 20_____, praying for leave to change ______________________________'s name to ______________________________, and the Court being satisfied by said petition that it is true and that there is no reasonable objection to the change of name proposed. NOW on motion of _______________________________, Petitioner, it is hereby ORDERED that the Petitioner ________________________________ having been born on _______________________ in _________________________________, (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 of the present name, upon full compliance with this Order and the filing of the affidavit of publication hereinafter specified, and it is further, American LegalNet, Inc. www.FormsWorkFlow.com ORDERED that this Order be entered and the papers on which it was granted be filed prior to the publication hereinafter directed in the office of the County Clerk of ____________________ County, and that notice of this Order be published within sixty (60) days after the making of this Order in the ________________________________, a newspaper published in the County of _______________________, at least once, in substantially the following form as prescribed in Section 63 of the Civil Rights Law of the State of New York, Notice is hereby given that an order entered by the Supreme Court, _______________________ County, on the ________ day of ____________________, 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 ___________________________________. and an affidavit of such publication shall be filed in the _______________________ County Clerk's Office within ninety (90) days after the making of this Order; and it is further ORDERED that upon full compliance with the above provisions of this Order, the Petitioner shall be known by the name of ________________________________ which ________________________________ is authorized to assume and by no other name. ENTER: ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com