Civil Court of the City of New York County of in the Matter of the Application of Index Number PETITION FOR FAMILY CHANGE OF NAME for Leave to Change Their Name(s) To My present name is: . For each of the following questions, place your initials in the appropriate column. YES NO a) Have you ever been convicted of a crime? b) Have you ever been adjudicated a bankrupt? c) Are there judgments or liens of record against you? d) Are there any actions or proceedings pending to which you are a party? If your answer is ''YES'' to any of the four questions above, give particulars below in sufficient detail to readily identify the matter referred to: (If additional space is required, attach (a) separate sheet(s) of paper with the details.) For each of the following questions, place your initials in the appropriate column. YES NO a) Do you have any minor children? b) Do you have any obligations for child support? c) If yes, are the child support payments satisfied and up to date? What is the amount of child support arrearage that is currently outstanding? Which Court issued the child support order? Which County Child Support Collections Unit is involved? d) Are you responsible for spousal support? e) If yes, are the spousal support payments satisfied and up to date? What is the amount of spousal support arrearage that is currently outstanding? Which Court issued the spousal support order? CIV-GP-82F Page 3 Supplemental American LegalNet, Inc. www.FormsWorkflow.com