Petition For Change Of Adult'S Name - New York Supreme Court (Page 5 of 6) in pdf

Petition For Change Of Adult'S Name - New York Supreme Court Page 5

[Fill in the spaces next to the instructions.]

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]

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STATE OF NEW YORK}

SS. :}

COUNTY OF

}

[23. Insert County where papers signed and notarized]

[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]

Petition For Change Of Adult'S Name - New York Supreme Court Page 5