_________Court of the State of New York
County of _________________________________
---------------------------------------------------------------x
In the Matter of the Application of CONSENT
____________________________________ TO MINOR’S
CHANGE OF NAME
As Parent and Natural Guardian for leave
to Change Minor’s Name To Index # _________________
_____________________________________
---------------------------------------------------------------x
STATE OF NEW YORK, COUNTY OF ______________________ss.:
_________________________________________________, being duly sworn, says:
I am over the age of eighteen fourteen years of age or over and reside at
____________________________________________________________________________
I am the parent of the Minor child the Minor child herein.
I have read the within Petition dated _________________________, requesting a change
of name from _______________________________________________________________ to
________________________________________________________________.
I consent to such change.
________________________________________
Signature of Affiant in the presence of the Notary
Sworn to before me this
_______ day of __________, 20____.
______________________________
Notary Public
