________Court of the State 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)
