Civil Court of the City of New York
County of ______________________ Index Number _________________
In the Matter of the Application of
PETITION FOR
INDIVIDUAL ADULT
for Leave to Change His/Her Name To CHANGE OF NAME
____________________________________
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.
5. My present residence is: _____________________________________________________________________
6. For each of the following five statements, place your initials in the appropriate column. YES NO
a) The disclosure and publication of this name change would jeopardize my personal safety ______ ______
b) I have been convicted of a crime ______ ______
c) I have been adjudicated a bankrupt ______ ______
d) There judgments or liens of record against me ______ ______
e) There is/are an/action(s) or proceeding(s) pending to which I am a party ______ ______
If your answer is YES to any of the five statements above, state the statement to which you responded yes and 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 statements, place your initials in the appropriate column. YES NO
a) I have any minor children ______ ______
b) I have (an) obligation(s) for child support ______ ______
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CIV-GP-82A Page 1 (Revised August 2009)
PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME - PAGE 2 of 3 Index no.
If you responded yes to question 7.(b) you must respond to the following:
The child support payments are satisfied and up to date.................................. ______ ______
Write the information in the column.
The amount of child support arrearage that is currently outstanding ... __________________
The Court that issued the child support order is................................................... __________________
The County Child Support Collections Unit that is involved is............................... __________________
Place your initials in the appropriate column YES NO
c) I am responsible for spousal support? ______ ______
If yes,
The spousal support payment(s) is/are satisfied and up to date ______ ______
Write the information in the column.
The amount of spousal support arrears that is currently outstanding is _________________
The Court that issued the spousal support order is _________________
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 application 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
CIV-GP-82A page 2 (Revised August 2009)
PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME - PAGE 3 of 3 Index no.
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.
Sworn to before me this __________ day of __________, 20____
____________________________________________________ ______________________________
Signature of Notary Public Signature of Petitioner
CIV-GP-82A page 3 (Revised August 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.