Affidavit In Support Of Nunc Pro Tunc Order- Change Of Infant'S Name - New York Supreme Court

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[Fill in the spaces next to the instructions. Sign in front of a Notary Public.]
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NASSAU
----------------------------------------------------------------------------x
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 IN SUPPORT
OF NUNC PRO TUNC
ORDER- CHANGE
OF INFANT’S NAME
___________________________________________,
[3. Fill in infant current name]
FOR LEAVE TO CHANGE INFANT(S) NAME(S) TO
___________________________________________,
[4. Fill in infant new name(s)]
-----------------------------------------------------------------------------x
TO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:
I, [5. Your name]
, the petitioner, being
duly sworn hereby state the reason(s) I failed to comply with the Ordered provisions of
the Name Change Order signed by Justice [6. Insert Justice’s name from Order]
on, [7. Insert date from Order]
is/are as follows: [8. Explain your reasons for the application.]

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