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

[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

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In the Matter of the Application of

[1. Index No. & Year]

Index No.

[2. Fill in name(s)]

______________/_____

FOR LEAVE TO CHANGE NAME TO

AFFIDAVIT IN SUPPORT

OF NUNC PRO TUNC

ORDER CHANGE OF

ADULT’S NAME

[3. Fill in new name]

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TO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:

I, [4. 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 [5. Insert Justice’s name from Order]

on, [6. Insert date from Order]

is/are as follows: [7. Explain your reasons for the application.]

I further state that I have made no previous application has been made for this relief

before this or any other court of competent jurisdiction.

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