Petition For Change Of Adult'S Name - New York Supreme Court

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[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
----------------------------------------------------------------------------x
In the Matter of the Application of
[1. Index No. & Year]
,
Index No.
[2. Fill in Your Name from Birth Certificate/
/
or Naturalization Certificate]
PETITION FOR CHANGE
OF ADULT’S NAME
FOR LEAVE TO CHANGE HIS/HER NAME TO
,
[3. Fill in new name]
-----------------------------------------------------------------------------x
TO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF NASSAU:
The petition of [4. Your name from Birth/ Naturalization Certificate]
respectfully show to the court the following:
1. I am a resident of Nassau County, residing at [5. Your address]
2. I was born at [6. Insert Town/City, County, State and Country.]
3. I was born on [7. Insert date of birth.]
4. I attach hereto as proof of my name and date of birth a certified copy of my birth
certificate. [8. Attach certified copy of your birth certificate/naturalization certificate.]
5. I am a citizen of [9. Select one.]
The United States
A Foreign Country [ 9a. If checked, complete information below]
Country [9b. Insert Country]
Alien Registration Number [9c. Number]

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