Petition For Change Of Adult'S Name - New York Supreme Court Page 5
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SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NASSAU
----------------------------------------------------------------------------x
In the Matter of the Application of
[20. Index No. & Year]
,
Index No.
[21. Your name from Birth/ Naturalization Certificate]
/
VERIFICATION
FOR LEAVE TO CHANGE HIS/HER NAME TO
,
[22. Fill in new name]
-----------------------------------------------------------------------------x
STATE OF NEW YORK}
SS. :}
COUNTY OF
}
[23. Insert County where papers signed and notarized]
I,
[24. Your name from Birth/
Naturalization Certificate] , being duly sworn, deposes and says: I am the Petitioner in
this matter.
I have read the foregoing petition and know the contents thereof. The same are true
to my knowledge, except as to matters therein stated to be alleged on information and
belief and as to those matters I believe them to be true
[25. SIGN YOUR NAME BEFORE NOTARY]
[26. PRINT YOUR NAME]
Sworn to before me this
day of
Notary Public
[27. Verification must be notarized]
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