Petition For Individual Minors Change Of 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
INDIVIDUAL MINOR’S
CHANGE OF NAME
As Parent and Natural Guardian for leave
to Change Minor’s Name To
______________________________________
1.
________________________________________________________________, by this petition, alleges
2.
I am the _____________________________________________________________________ of a Minor
3.
The Minor’s present name is _____________________________________________________________.
4.
The name which I propose that the Minor will assume in place and stead of the Minor’s present name is:
_____________________________________________________________________________________.
5.
The Minor’s Age, Date of Birth and Place of Birth are: Age:__________ Date of Birth:________________
Place of Birth: _________________________________________________________________.
Note: If the Minor was born in the State of New York you must attach either: a) a Birth Certificate, b) a
Certified Transcript of such Birth Certificate, or c) a Certificate from the Commissioner or the local Board of
Health that no such Certificate is available.
6.
The Minor’s present residence is: __________________________________________________________
7.
For each of the following five statements , place your initials in the appropriate column.
YES
NO
a) The Minor’s personal safety would be jeopardized by the disclosure of this name change. ______ ______
b) The Minor has been convicted of a crime
______ ______
c) The Minor has been adjudicated a bankrupt
______ ______
d) There are judgments or liens of record against the Minor
______ ______
e) There is/are actions or proceedings pending to which the Minor is a party
______ ______
If you responded “YES” to any of the five statements above, please explain:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(If additional space is required, attach (a) separate sheet(s) of paper with the details.)
)
CIV-GP-82M Page 1(Revised August 2009
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