_________Court of the State of New York
County of _________________________________
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In the Matter of the Application of PETITION FOR
____________________________________ INDIVIDUAL MINOR’S
CHANGE OF NAME
As Parent and Natural Guardian for leave
to Change Minor’s Name To Index # _________________
_____________________________________
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1. ________________________________________________________________, by this petition, alleges
2. I am the _____________________________________________________________________ of a Minor.
3. The Minor’s present name is _____________________________________________________________.
4. The name which I propose that the Minor will assume in place and stead of the Minor’s present name is:
_____________________________________________________________________________________.
5. The Minor’s Age, Date of Birth and Place of Birth are: Age:__________ Date of Birth:________________
Place of Birth: _________________________________________________________________.
Note: If the Minor was 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.
6. The Minor’s present residence is: __________________________________________________________
7. For each of the following five statements , place your initials in the appropriate column.
YES NO
a) The Minor’s personal safety would be jeopardized by the disclosure of this name change
b) The Minor has been convicted of a crime
c) The Minor has been adjudicated a bankrupt
d) There are judgments or liens of record against the Minor
e) There is/are actions or proceedings pending to which the Minor is a party
If you responded “YES” to any of the five statements above, please explain:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(If additional space is required, attach (a) separate sheet(s) of paper with the details.)
