CONNECTICUT PROBATE COURTS
Petition for Change
of Name (Adult)
PC-901 REV. 8/19
Petition for Change of Name (Adult) PC-901
RECEIVED:
Instructions: 1) An individual 18 years of age or older may use this form to petition for a change of his or her name.
2)
The petition must be filed in the court for the probate district in which the petitioner resides and
be accompanied by a) PC-910, Affidavit RE Change of Name,
b) a certified copy of the petitioner’s long-
form birth certificate, c) two forms of identification, one of which must be photographic identification,
and d) Confidential Sheet, PC-901CI , with the petitioner's confidential social security number.
3)
The court will conduct a search of the sex offender registry and of the registry of offenders convicted of
crimes with a deadly weapon and may conduct a full criminal background check.
4) For mo
re information, see Probate Court Rules of Procedure sections 47.1 and 47.4.
5)
Type or print in ink. Use an additional sheet, or PC-180, if more space is needed.
Probate Court Name
Dist
rict Number
Petitioner’s
Cur
rent Name:
First
Middle
Last
Petitioner’s Address and Telephone Number
Date of Birth
Place of Birth
Name on Birth Certificate (if different)
Name to be
Changed to:
First
Middle
Last
Spouse (Name, address and telephone number)
The petitioner represents that:
A change of name is sought for the following reasons:
The purpose of seeking a change of name is not to deceive, defraud or mislead any person or governmental agency, nor
to avoid the legal consequences of a criminal conviction, but solely for the reason(s) stated above.
WHEREFORE, the petitioner requests a change of name to the name stated above.
The representations made in this petition are made under penalty of false statement.
Signature of Petitioner
Type or Print Name
Date
