[Fill in the spaces next to the instructions. Attach copies of the indicateddocuments and mark them as exhibits.]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 Your Name from Birth Certificate/ / or Naturalization Certificate]PETITION FOR CHANGEOF ADULT222S NAMEFOR LEAVE TO CHANGE HIS/HER NAME TO ,[3. Fill in new name] -----------------------------------------------------------------------------xTO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:The petition of [4. Your name from Birth/ Naturalization Certificate] respectfully show to the court the following:1.I am a resident of Nassau County, residing at [5. Your address] 2.I was born at [6. Insert Town/City, County, State and Country.] 3.I was born on [7. Insert date of birth.] 4.I attach hereto as proof of my name and date of birth a certified copy of my birthcertificate. [8. Attach certified copy of your birth certificate/naturalization certificate.]5.I am a citizen of [9. Select one.] The United States A Foreign Country [ 9a. If checked, complete information below] Country [9b. Insert Country] Alien Registration Number [9c. Number] American LegalNet, Inc. www.FormsWorkFlow.com 6.I am Single Married Divorced Separated.7.The petitioner is is not responsible for child support obligation. [10. If the petitioner is responsible for child support obligations attach aseparate statement.]8.The petitioner is is not responsible for a maintenance/ alimony obligation. [11.If the petitioner is responsible for maintenance/alimony obligations attacha separate statement.] 9.I wish to change my name for the following reasons[12. Explain your reasons for the application.] 10.I hereby state under the penalty of perjury that: I have no judgments or liens ofrecord against said me nor against any property in my name. I am not party to any actionor proceeding is pending. I have never been adjudicated a bankrupt. In fact, no proceedingin bankruptcy has ever been instituted by or against mein any court or before any officerof the state or of the United States, nor have I at any time made an assignment for thebenefit of creditors. There are no claims, demands, liabilities or obligations on a written American LegalNet, Inc. www.FormsWorkFlow.com instrument or otherwise against me or to which said I am a party. I have no creditors andno person will be adversely affected nor prejudiced in any way by the proposed change ofname. Except as stated below:[13. If any of the above statements are not true,complete an explanation of circumstances below] 11.I hereby state under the penalty of perjury that: I have not been convicted of acrime. Except as stated below:[14. If any of the above statements are not true,complete an explanation of circumstances below] 12.No previous application has been made for this relief before this or any othercourt of competent jurisdiction. Except as stated below:[15. If any of the abovestatements are not true, complete an explanation of circumstances below] American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your petitioner respectfully prays that an order be grantedpermitting said the petitioner to assume the name of [16. Insert new name] .[17. Date and County papers are signed in] Dated: Petitioner Signature[18. Your signature] Print Petitioner Name[19. Print Your Name] American LegalNet, Inc. www.FormsWorkFlow.com [Fill in the spaces next to the instructions.]SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF NASSAU----------------------------------------------------------------------------xIn the Matter of the Application of[20. Index No. & Year] ,Index No. [21. Your name from Birth/ Naturalization Certificate] / VERIFICATIONFOR LEAVE TO CHANGE HIS/HER NAME TO ,[22. Fill in new name] -----------------------------------------------------------------------------xSTATE OF NEW YORK}SS. :} COUNTY OF }[23. Insert County where papers signed and notarized] I, [24. Your name from Birth/Naturalization Certificate] , being duly sworn, deposes and says: I am the Petitioner inthis matter.I have read the foregoing petition and know the contents thereof. The same are trueto my knowledge, except as to matters therein stated to be alleged on information andbelief and as to those matters I believe them to be true [25. SIGN YOUR NAME BEFORE NOTARY] [26. PRINT YOUR NAME] Sworn to before me this day of Notary Public[27. Verification 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 , [1. Index No. & Year]Index No. / PETITION FOR CHANGEOF ADULT222S NAME , -----------------------------------------------------------------------------xTO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:The petition of to the court the following: 1.I am a resident of Nassau County, residing at 2.I was born at 3.I was born on 4.I attach hereto as proof of my name and date of birth a certified copy of my birthcertificate. 5.I am a citizen of The United States A Foreign Country Country Alien Registration Number 6.I am Single Married Divorced Separated. American LegalNet, Inc. www.FormsWorkFlow.com 7.The petitioner i 8.The petitioner 9.I wish to change my name for the following reasons 10.I hereby state under the penalty of perjury that: I have no judgments or liensofrecord against said me nor against any property in my name. I am not party to any actionor proceeding is pending. I have never been adjudicated a bankrupt. In fact, no proceedingin bankruptcy has ever been instituted by or against mein any court or before any officerof the state or of the United States, nor have I at any time made an assignment for thebenefit of creditors. There are no claims, demands, liabilities or obligations on a written is not responsible for child support obligation. is not responsible for a maintenance/alimonyobligation. American LegalNet, Inc. www.FormsWorkFlow.com 11.I hereby state under the penalty of perjury that: I have not been convictedofacrime. Except as stated below: 12.No previous application has been made for this relief before this or anyothercourt of competent jurisdiction. Except as stated below: American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your petitioner respectfully prays that an order be grantedpermitting said the petitioner to assume the name of . [17. Date and County papers are signed in]Dated: Petitioner Signature Print Petitioner Name American LegalNet, Inc. www.FormsWorkFlow.com [20. Index No. & Year]Index No. / VERIFICATION Sworn to before me this day of Notary Public SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF NASSAU----------------------------------------------------------------------------xIn the Matter of the Application of,FOR LEAVE TO CHANGE HIS/HER NAME TO----------------------------------------------------------------------------xSTATE OF NEW YORK} SS. :}COUNTY OF }, being duly sworn, deposes and says: I am the Petitionerinthis matter.I have read the foregoing petition and know the contents thereof. The same are trueto my knowledge, except as to matters therein stated to be alleged on information andbelief and as to those matters I believe them to be true American LegalNet, Inc. www.FormsWorkFlow.com