Civil Court of the City of New York County of Index Number In the Matter of the Application of PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME for Leave to Change His/Her Name To 1. by this petition, alleges 2. My present name is: 3. The name which I propose to assume in place and stead of my present name is: 4. My Age, Date of Birth and Place of Birth are: Age: Date of Birth: Place of Birth: Note: If you were born in the State Of New York you must attach either: a) a Birth Certificate, b) a Certified Transcript of such Birth Certificate, or c) a Certificate from the Commissioner or the local Board of Health that no such Certificate is available. I 5. My present residence is: 6. For each of the following four 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.) 7. 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? CIV-GP-82A page 1 (Revised November, 2006) American LegalNet, Inc. www.FormsWorkflow.com PETITIONER FOR INDIVIDUAL ADULT CHANGE OF NAME - PAGE 2 YES NO 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? 8. I have/have not made a previous application to change my name in this or any other Court. (Strike out one) (If you have, give details and reason for this current a location below.) 9. The reasons for this application are as follows: 10. WHEREFORE, your Petitioner respectfully requests that an Order be granted permitting this change of name. Date Signature of Petitioner VERIFICATION State of New York, County of ss.: being duly sworn, deposes and says: s/he is the petitioner named above, that petitioner has read the petition and knows the truth of the contents thereof except for those matters alleged to be on information and belief, and as to those matters, petitioner believes them to be true. I Sworn to before me this day of Signature of Notary Public CIV-GP-82A page 2 (Revised November, 2006) 20 Signature of Petitioner American LegalNet, Inc. www.FormsWorkflow.com