Affidavit In Support Of Nunc Pro Tunc Order- Change Of Infant'S Name - New York Supreme Court Page 3

SUPREME COURT OF THE STATE OF NEW YORK

COUNTY OF NASSAU

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In the Matter of the Application of

[20. Index No. & Year]

___________________________________________,

Index No.

[21. Fill in name(s)]

______________/_____

individually and as parent or guardian of the infant(s)

___________________________________________,

[22. Fill in infant current name]

FOR LEAVE TO CHANGE INFANT(S) NAME(S) TO

___________________________________________,

[23. Fill in infant new name(s)]

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_____________________________________________________________________

[24. Insert name(s) of papers submitted]

[25. YOUR SIGNATURE]

_____________________________________________

[26. PRINT YOUR NAME]

[27. YOUR ADDRESS]

[28. CITY, STATE ZIP CODE]

[29. YOUR PHONE NUMBER]

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Parent category: Legal