Civil Court of the City of New York
County of ______________________ Index Number _________________
In the Matter of the Application of PETITION FOR
CHANGE OF NAME
As Parent and Natural Guardian for leave
to Change Minor’s Name To
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 M inor’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.
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 M inor 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 M inor 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.)
CIV-GP-82M Page 1(Revised August 2009)