[Fill in the spaces next to the instructions. Other spaces are for Court use.]
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NASSAU
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In the Matter of the Application of
[1. Index No. & Year]
___________________________________________,
Index No.
[2. Fill in name(s)]
______________/_____
individually and as parent or guardian of the infant(s)
AFFIDAVIT OF CONSENT
OF INFANT OF THE AGE
___________________________________________,
OF FOURTEEN (14)
[3. Fill in infant current name]
YEARS OR OLDER
FOR LEAVE TO CHANGE INFANT(S) NAME(S) TO
___________________________________________,
[4. Fill in infant new name(s)]
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STATE OF NEW YORK,
ss}
COUNTY OF NASSAU:
I, [5. Current Infant name]
being duly
sworn, deposes and says: that deponent is the infant in the within proceeding; has read
the foregoing petition of [6. Insert Name of Petitioner]
and joins in the prayer for relief and consents thereto.
[7. Infant Signature]
[8. Print Name]
Sworn to before me this
day of ______________, 20 __
Notary Public