Petition For Change Of Family Name
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1
2Civil Court of the City of New York
County of ______________________
Index Number _________________
In the Matter of the Application of
PETITION FOR
FAMILY
CHANGE OF NAME
for Leave to Change Their Name(s) To
_____________________________________
____________________________(and ___________________________), by this petition, allege(s)
Primary Adult
(Second Adult, if any)
1.
The present family name is: ______________________________________________________.
2.
The new name which we propose to assume in place and stead of the present name is:
_____________________________________________________________________________.
3.
The individuals* whose names are included in this application are incorporated herewith are as follows:
Present Name
Proposed Name
Place of Birth
Date of Birth
Present Age
_________________________ ___________________
_____________
____________ _____________
_________________________ ___________________
_____________
____________ _____________
_________________________ ___________________
_____________
____________ _____________
_________________________ ___________________
_____________
____________ _____________
_________________________ ___________________
_____________
____________ _____________
_________________________ ___________________
_____________
____________ _____________
_________________________ ___________________
_____________
____________ _____________
*Primary Adult (and Secondary Adult, if any) and all minors under the age of 18 should be listed. Minors
between the ages of 14 and 18 must consent to this change by signing the Consent on page 2.
4.
The disclosure and publication of this name change would jeopardize one/all of the applicant’s personal safety
YES_______
NO________ because _________________________________________________________________
____________________________________________________________________________________________________
5.
One/some/all of the above named applicants have been convicted of a crime, adjudicated a bankrupt, or there is/are
judgments or liens against an applicant, or there is/are actions or proceedings pending against an applicant, or an applicant has
an obligation(s) for child and/or spousal support.
YES*_______
NO________
*If the answer to any part of this statement is YES for any applicant, each applicant who answers YES must fill out a CIV-
GP-82F supplemental form.
6.
Our present residence is: _______________________________________________________________________________
7.
The reasons for this application are as follows: ______________________________________________________________
____________________________________________________________________________________________________
CIV-GP-82F Page 1 (Revised September 2009)
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