Civil Court of the City of New York
County of ______________________ Index Number _________________
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
______________________________________
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 inors 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 Minors 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 respondedYES 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)
PETITIO NER FO R INDIVIDUAL M INORS CHANGE O F NAM E - PAGE 2 Index No.______________
8. I have/have not made a previous application to change the M inors 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
VERIFICATIO N
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-82M Page 2 (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.
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