[Fill in the spaces next to the instructions. Attach copies of the indicated
documents and mark them as exhibits.]
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)
PETITION FOR 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)]
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TO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:
[5. Your name]
by this petition
alleges that he/she is the [6.Circle one] natural father/mother of the infant named herein,
and resides at [7. Your address]
and further
alleges that:
1. Said infant's name is [8. Insert infant current name]
2. The name which said infant proposes to assume is [9. Insert infant new name]
3. Said infant resides at [10. Insert infant address, No Post Office Box.]
4. Said infant is of the age of [11. Insert infant age.]
5. Said infant date of birth is [12. Insert infant date of birth.]
6. Said infant place of birth is [13. Insert County, State and Country.]