[Fill in the spaces next to the instructions. Sign in front of a Notary Public.]SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF NASSAU----------------------------------------------------------------------------xIn the Matter of the Application of[1. Index No. & Year] ,Index No.[2. Fill in name(s)] /FOR LEAVE TO CHANGE NAME TOAFFIDAVIT IN SUPPORTOF NUNC PRO TUNCORDER CHANGE OF ,ADULT222S NAME[3. Fill in new name]-----------------------------------------------------------------------------xTO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU: I, [4. Your name] , the petitioner, beingduly sworn hereby state the reason(s) I failed to comply with the Ordered provisions ofthe Name Change Order signed by Justice [5. Insert Justice222s name from Order] on, [6. Insert date from Order] is/are as follows: [7. Explain your reasons for the application.] I further state that I have made no previous application has been made for this reliefbefore this or any other court of competent jurisdiction. American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your petitioner respectfully asks that the Court grant me this Nunc ProTunc order allowing me an additional sixty (60) days to comply with the terms of theaforementioned order [8. SIGN YOUR NAME BEFORE NOTARY] [9. PRINT YOUR NAME]Sworn to before me thisday of , 20 Notary Public[10. Affidavit must be notarized] American LegalNet, Inc. www.FormsWorkFlow.com SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF NASSAU----------------------------------------------------------------------------xIn the Matter of the Application of[18. Index No. & Year] ,Index No.[19. Fill in name(s)] /FOR LEAVE TO CHANGE NAME TOAFFIDAVIT IN SUPPORTOF NUNC PRO TUNCORDER CHANGE OF ,ADULT222S NAME[20. Fill in new name]-----------------------------------------------------------------------------x[21. Insert name(s) of papers submitted] [22. YOUR SIGNATURE] [23. PRINT YOUR NAME] [24. YOUR ADDRESS] [25. CITY, STATE ZIP CODE] [26. YOUR PHONE NUMBER] American LegalNet, Inc. www.FormsWorkFlow.com SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF NASSAU----------------------------------------------------------------------------xIn the Matter of the Application of , FOR LEAVE TO CHANGENAME TO Index No./AFFIDAVIT IN SUPPORTOF NUNC PRO TUNCORDER CHANGE OFADULT222S NAME ,[3. Fill in new name]----------------------------------------------------------------------------x I further state that I have made no previous application has been made for this reliefbefore this or any other court of competent jurisdiction. TO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:I,, the petitioner, beingduly sworn hereby state he reason(s) I failed to comply with the Ordered provisions ofthe Name Change Order signed by Justice American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your petitioner respectfully asks that the Court grant me this Nunc ProTunc order allowing me an additional sixty (60) days to comply with the terms of theaforementioned order Sworn to before me thisday of , 20 Notary Public American LegalNet, Inc. www.FormsWorkFlow.com SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF NASSAU----------------------------------------------------------------------------xIn the Matter of the Application of , [19. Fill in name(s)]FOR LEAVE TO CHANGE NAME TO , Index No./AFFIDAVIT IN OF NUNC PRO TUNCORDER CHANGE OFADULT222S NAME [20. Fill in new name]--------------------------------------------------------------------------x [22. YOUR SIGNATURE] American LegalNet, Inc. www.FormsWorkFlow.com