Fillable Civil Court of the City of New York (NYS Unified Court System Division of Technology)

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Civil Court of the City of New York (NYS Unified Court System Division of Technology)

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Civil Court of the City of New York
County of ______________________ Index Number _________________
In the Matter of the Application of PETITION FOR
FAMILY
CHANGE OF NAME
for Leave to Change Their Name(s) To
_____________________________________
____________________________(and ___________________________), by this petition, allege(s)
Primary Adult (Second Adult, if any)
1. The present family name is: ______________________________________________________.
2. The new name which we propose to assume in place and stead of the present name is:
_____________________________________________________________________________.
3. The individuals* whose names are included in this application are incorporated herewith are as follows:
Present Name Proposed Name Place of Birth Date of Birth Present Age
_________________________ ___________________ _____________ ____________ _____________
_________________________ ___________________ _____________ ____________ _____________
_________________________ ___________________ _____________ ____________ _____________
_________________________ ___________________ _____________ ____________ _____________
_________________________ ___________________ _____________ ____________ _____________
_________________________ ___________________ _____________ ____________ _____________
_________________________ ___________________ _____________ ____________ _____________
*Primary Adult (and Secondary Adult, if any) and all minors under the age of 18 should be listed. Minors
between the ages of 14 and 18 must consent to this change by signing the Consent on page 2.
4. The disclosure and publication of this name change would jeopardize one/all of the applicant’s personal safety
YES_______ NO________ because _________________________________________________________________
____________________________________________________________________________________________________
5. One/some/all of the above named applicants have been convicted of a crime, adjudicated a bankrupt, or there is/are
judgments or liens against an applicant, or there is/are actions or proceedings pending against an applicant, or an applicant has
an obligation(s) for child and/or spousal support. YES*_______ NO________
*If the answer to any part of this statement is YES for any applicant, each applicant who answers YES must fill out a CIV-
GP-82F supplemental form.
6. Our present residence is: _______________________________________________________________________________
7. The reasons for this application are as follows: ______________________________________________________________
____________________________________________________________________________________________________
CIV-GP-82F Page 1 (Revised September 2009)
PETITION FOR FAMILY CHANGE OF NAME - PAGE 2 of 2 Index no.
8. WHEREFORE, your Petitioner(s) respectfully request(s) that an Order be granted permitting this requested change of name.
__________________________ __________________________________
Date Signature of Petitioner
___________________________________
Signature of Second Adult
CONSENTS
I, _________________________________, am 14 years of age or over, and less than 18 years of age, and I have read
the annexed petition for family change of name, and I consent to the same.
___________________________________ _______________________________
Date Signature
I, _________________________________, am 14 years of age or over, and less than 18 years of age, and I have read
the annexed petition for family change of name, and I consent to the same.
___________________________________ _______________________________
Date Signature
I, _________________________________, am 14 years of age or over, and less than 18 years of age, and I have read
the annexed petition for family change of name, and I consent to the same.
___________________________________ _______________________________
Date Signature
I, _________________________________, am 14 years of age or over, and less than 18 years of age, and I have read
the annexed petition for family change of name, and I consent to the same.
___________________________________ _______________________________
Date Signature
VERIFICATION
State of New York, County of ___________ss.:
_____________________________________________________________, being duly sworn, deposes and say(s):
s/he/they is(are) the petitioner(s) named above, that s/he/they has/have read the petition and know(s) the truth of the contents
thereof except for those matters alleged to be on information and belief, and as to those matters, s/he/they believe(s) them to be
true, and that the signature(s) of the consenting party (parties) above is/are the true signature(s) of the minor child(ren) who is/are
included in the petition.
__________________________________ ____________________________________________
Signature of Petitioner Signature of Second Adult
Sworn to before me this ____ day of ________, 20___ Sworn to before me this _____ day of _________, 20___
_______________________________________ _______________________________________
Signature of Notary Public Signature of Notary Public
CIV-GP-82F Page 2 (Revised September 2009)
FREE CIVIL COURT FORM
No fee may be charged to fill in this form.
Form can be found at: http://www.nycourts.gov/courts/nyc/civil/forms.shtml.
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Civil Court of the City of New York (NYS Unified Court System Division of Technology)

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Completed 21 July 2020

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