SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF ________________________________________________x IN THE MATTER OF THE APPLICATION OF PETITION ________________________________________________ FOR LEAVE TO CHANGE HIS/HER NAME TO INDEX NUMBER____________ ________________________________________________ ________________________________________________x TO THE SUPREME COURT OF THE STATE OF NEW YORK: The petition of _______________________, respectfully shows to this court: 1. The petitioner’s name is ____________________________. 2. The petitioner resides at __________________________Street, ________________ _________________________, New York, County of _______________________. 3. The petitioner was born on ____________________, 19________, at ___________ ________________, New York, and is now _____________years of age. Attached hereto and made a part hereof is a certified transcript of the petitioner’s birth certificate or a certificate of the Commissioner of Health that the Petitioner’s birth certificate is not available. 4. The petitioner wishes to discard his/her present name and assume the name of _______________________________________________. 5. The petitioner is a citizen of the United States. 6. The petitioner has never been convicted of a crime. 7. The petitioner has never been adjudicated or bankrupt. 8. There are no judgments or liens of record against the petitioner or actions or proceedings pending to which the petitioner is a party. 9. The grounds of this application to change petitioner’s name are as follows: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com PETITION PAGE -2- 10. No previous application has been made for the relief sought herein. WHEREFORE, petitioner respectfully prays for an order permitting him/her to assume the name______________________________________. DATED:_____________________, NEW YORK _____________________, 20_________ _________________________ PETITIONER ______________________, being duly sworn, deposes and says: I am the petitioner in the above-captioned action. I have read the petition and know the contents to be true to my own knowledge, except to those matters alleged on information and belief and as to those matters I believe them to be true. _________________________ PETITIONER Sworn to before me on the the______________day of ___________________, 20______. ____________________________ NOTARY American LegalNet, Inc. www.USCourtForms.com