NAME CHANGES
FOR TRANSGENDER
ADULTS IN NEW
YORK STATE
PRISONS
Last Updated Spring 2017

LEGAL DISCLAIMER
This manual was written by the staff at the Sylvia Rivera Law
Project. We would like to thank Anya Morgan, SRLP’s summer
2016 intern, and Kim Barr, SRLP’s fall 2016 intern, for intensive
edits. The information contained herein is not intended as legal
advice or representation nor should you consider it as such.
Additionally, your use of this guide should not be construed as
creating an attorney-client relationship with the Sylvia Rivera
Law Project. We have attempted to provide information that is
up to date and useful. However, because the law changes, we
cannot guarantee that this information is current or correct.

A DIY
Guide for
Pro Se
Name
Changes

TABLE OF CONTENTS
INTRODUCTION

3

STEP 1: BEGINNING THE PROCESS

4

STEP 2: EXHIBIT GATHERING

4

STEP 3: DRAFTING AND REVIEWING THE PETITION AND ORDER

7

STEP 4: FILING THE PETITION, ORDER, AND INITIAL NOTICE

8

STEP 5: THE HEARING

9

STEP 6: NOTICE AND PUBLICATION
STEP 7: COMPLETION OF THE PROCESS
GLOSSARY

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10
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APPENDIX A: NYS LAW: ARTICLE 6 CHANGE OF NAME

12

APPENDIX B: NAME CHANGE QUESTIONS

17

APPENDIX C: NEW YORK PENAL LAW § 70.02

21

APPENDIX D: NYC BIRTH CERTIFICATE

24

APPENDIX E: NYS BIRTH CERTIFICATE REQUEST

26

APPENDIX F: SAMPLE PETITION AND SAMPLE ORDER

28

APPENDIX G: LIST OF NYS COUNTY CLERKS

35

APPENDIX H: FILING FEE WAIVER PAPERWORK

40

APPENDIX I: NOTICE OF PETITION

46

APPENDIX J: DRAFT AFFIDAVIT OF SERVING

48

APPENDIX K: LEGAL SERVICE ADDRESSES

50

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INTRODUCTION
Congratulations on beginning your name change process! This can be such an exciting time. This
guide is aimed towards transgender, gender non-conforming, and intersex adults age 18 and
older currently held in New York State prisons. If you are under 18, if you are not incarcerated,
or if you are outside of New York State, then this is not the guide for you. Please write to us and
we will do our best to put you in touch with a better resource or organization.
The Sylvia Rivera Law Project (SRLP) was founded in 2002 and offers free direct legal services
to transgender, gender non-conforming, and intersex individuals in New York City and those
incarcerated by New York State. One of the largest legal concerns that occurs for our clients is
the issue of name changes. We wish we were a large enough organization to take on all of the
name change cases we see, but sadly we are not able to do this. So we made this guide to help
people begin this process on their own. We hope you find it helpful and easy to use.
Before you start working on your legal name change, you should take some time to make sure
you have a clear understanding of the process. It is particularly important that you understand
that a name change is not the same as changing your gender marker on your IDs. One may
change one’s name without changing one’s gender designation, and one may change one’s
gender designation without changing one’s name. In New York, there is no court process for a
gender change. Instead, you must go to each individual agency and comply with their rules for
updating or correcting your gender marker. These rules generally call for some sort of a doctor’s
letter.
The other common misconception is that once your name has been changed in court, it is
automatically updated everywhere else. Unfortunately, that is not the case. You will need to
inform each individual government agency, organization, or business about your name change –
including DOCCS. You can usually do this by filling out a form, producing a certified copy of
your name change order, and possibly paying a fee.
It is also important to keep in mind that for individuals who are incarcerated the process can take
anywhere between 3 to 12 months (though most of this time is spent waiting on documents).
In creating this guide we have done our best to provide a draft or template for every part of the
process so that you have something to look at to guide you. These are attached at the end of the
guide as Appendixes. We have also put in bold all words we think might need to be legally
defined and offered a definition of them in the Glossary. If you notice a word that we missed, or
if there are additional templates we should have included as appendixes, please let us know! You
can write to SRLP at:
Sylvia Rivera Law Project
Attn: Prisoner Justice Project
147 W. 24th Street, 5th Floor
New York, NY 10011

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STEP 1: BEGINNING THE PROCESS
The first step in a legal name change is to gather the information that you will need to draft the
Petition and Order and to assess what additional documentation you will need to gather for
Exhibits. You can look at the entire Name Change Statute in Appendix A. It can be helpful to
look at the Statute as you read this guide as it will clarify why you need to gather certain
documents.
SRLP has a name change questionnaire that is designed to help you figure out what documents
you need to gather for the Petition and Order. This is included as Appendix B. Even though
SRLP is not representing you in your name change, we still recommend filling out the
questionnaire to help you make a list of the additional documentation that may be needed (such
as child support orders, divorce orders, orders of judgment, etc.)
If you have prior criminal convictions, it is often best to attach a copy of your criminal history or
commitment papers as an Exhibit to the Petition. If you are incarcerated for conviction of a
violent felony, then the Docket Number and Penal Law Code (the legal code associated with
your crime of conviction; such as a crime of perjury in the third degree would be 210.05) should
be noted in the Petition. You should also list the court in which you were convicted and the date
of conviction. If you are not sure if your conviction is a violent felony or not, look at New York
Penal Law § 70.02 which is attached here as Appendix C.

STEP 2: EXHIBIT GATHERING
Sometimes this step is extremely quick and easy; other times, it is the most difficult part of the
name change process. The exhibits you need will vary somewhat based on your individual
circumstances, but the two exhibits you will certainly need are a birth certificate and criminal
records.
a.

Birth Certificate: The statute requires that an original or certified copy of your birth
certificate be attached to the petition for all petitioners born in New York State. The
statute does not say whether birth records for petitioners born outside of New York State
need to be shown in their original form. In practice, we have found that courts typically
require a birth certificate from all people seeking name changes; although, a photocopy of
the Petitioner’s birth certificate is generally adequate for those born outside of New York.
Regardless of the requirement, it is always a good idea to get a certified copy of your
birth certificate so you can verify that the information in your petition matches it exactly.
When you send the certified copy of your birth certificate to the court you will not get it
back. It becomes part of the permanent record.

People in prison are not permitted to personally possess their own certified copy or original birth
certificates, although it can be worth asking Inmate Records for a copy even if you anticipate
being turned down. Inmate Records in your facility will typically have your birth certificate on
file and will release a photocopy to an attorney or a family member with your permission. You
can also request that the court subpoena the birth certificate from the Office of Vital Records.
SRLP has never done this, but it is a possibility. At this time, we aren’t able to include any
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template subpoenas, but hopefully in the next version of this Guide we will be able to include a
template.
If there are no other options, you, an attorney, or a family member will have to order your birth
certificate from the record-keeping agency. In New York, it can be very difficult to request a
birth certificate without picture identification, even as an attorney. SRLP has negotiated
extensively both with the New York City Office of Vital Records and the New York State
Department of Health in an attempt to alleviate this difficulty, but thus far has been unsuccessful.
Below are suggestions for ordering your birth certificate if you were born in New York City,
New York State, or outside of New York:
i.

New York City. If you were born in New York City, you will have to mail the
request to the Office of Vital Records: Attn: Tracey Cornish, Office of Vital
Records, 125 Worth Street, CN-4, Room 133, New York, NY 10013-4090. A
birth certificate request form is attached as Appendix D. In your request, the
following documents should be enclosed:
Birth Certificate Application;
A photocopy of your birth certificate; and
A money order in the amount of $15.00 made out to the NYC Department
of Health and Mental Hygiene.
If an attorney or a family member is requesting the birth certificate for you, they
will also need to include:
A notarized authorization, authorizing the attorney/family member to request your birth certificate; and
If they’re an attorney, a photocopy of the attorney’s ABA photo identification card.
If your application is rejected, you should write to the Office of Vital Records,
125 Worth St., CN-4, Rm 144, New York, NY 10013-4090. The Office also
claims to accept the following forms of identification from individuals who are
unable to present picture identification:
Expired DL or ID with an address that is not current
Voter Registration Card
Social Security Card
Social Security printout that shows an individual’s name and number
Prison Photo ID with date of birth (DOB)
Prison Record or printout from the Correctional facility
Parole or release papers (state or federal)
Medical papers from a doctor or hospital
Old employment photo ID
Veteran’s Affairs photo ID
DD-214 or other military record

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W2 or 1099
Hospital Birth Certificate
Medicare or Medicaid Card and / or documents
Harris County Gold Card – indigent insurance
Court Order with full name and judge’s signature
School records – certified copy
Baptismal Certificate – certified copy
Early childhood immunization records
Marriage and / or divorce records
Selective Service Card
ii.

New York State. While the New York State Department of Health has
historically refused to issue birth certificates to the attorneys of people whom they
know to be incarcerated on the basis that prisoners are not permitted to possess
them, SRLP has been able to successfully negotiate a policy to request the birth
certificates on behalf of our clients. A birth certificate request form is attached as
Appendix E. The following documents must be sent to Karen Foggia,
Certification Unit, 800 North Pearl Street, Albany, NY 12204:
A cover letter (on law firm’s letterhead if the person requesting is an attorney);
Completed NYS Department of Health Birth Certificate Application;
Notarized Authorization signed by you authorizing your attorney/family
member to request a birth certificate on your behalf;
If they’re an attorney, a copy of attorney identification (or picture identification plus proof of current registration); and
A check for $30.00 payable to the NYS Department of Health.

iii. Outside of New York, in the United States. In many states, it is a lot easier for
an attorney to order a certified birth record on behalf of a client than it is in New
York. If you were born outside of New York but within the United States, it
makes sense to look into the procedure in your state of birth. Please write to
SRLP, Prisoners’ Legal Services of New York, Legal Aid Society’s Prisoners
Rights Project, or the Peter Cicchino Youth Project if you’d like us to send you
the information for your state. You can find their addresses in Appendix K. Often,
submitting a notarized release with the application is sufficient. If your attorney is
not able to get a certified copy of the birth certificate, they may be able to get a
photocopy from Inmate Records.
Once you find a way to get your birth certificate, ask whomever is holding it (Office of Vital
Records, an attorney, a loved one or family member) to send the birth certificate to the court
after you send in your petition and receive an Index Number. Remember, people in NYS
prisons cannot hold their birth certificates so having it sent to you could result in disciplinary
actions.
b.

Criminal convictions: When you are incarcerated, it is often best to just attach a copy of
you criminal history. You should be able to get a copy of your criminal history from

6

Inmate Records. If Inmate Records is unable or unwilling to provide you with a copy of
your criminal history, you should write the Division of Criminal Justice Services
(“DCJS”). DCJS will send you a free copy of your rap sheet if you write a letter to them
that includes your:
Name
Aliases (any other name you used for yourself or are known by to law enforcement or a
court)
Date of birth
DIN #
NYSID number (a unique number given by DCJS to identify and group your record), if
you have it. If you do not have it, that is okay.
Remaining time you will be incarcerated
The address for DCJS is:
New York State Division of Criminal Justice Services
Record Review Unit
Alfred E. Smith Building
80 South Swan Street
Albany, NY 12210
You must also declare criminal histories outside of New York State. Different states have
different procedures to send away for one’s rap sheet on one’s own. Some states require only
filling out a brief form online. Information on how to get criminal histories from different states
is available online – please write to SRLP, Prisoners’ Legal Services of New York, Legal Aid
Society’s Prisoners Rights Project, or the Peter Cicchino Youth Project, and we can write back to
you with the physical address for your state. If the convictions are from multiple states, it is
easiest to get an FBI rap sheet to avoid having to deal with each state individually. You may be
able to obtain your own criminal record. Your public defender is also certain to have it.
c. Other. Depending on the circumstances of the case, you might find that it’s useful to
include other sorts of documentation, such as bankruptcy judgments or an order from a
previous name change in your exhibits. For these documents you must write to the court
where the action occurred and request a certified copy of the order. Most counties
require that a fee be paid for receiving a copy and an additional fee for certifying the
document. When you write, you may ask the Clerk if your fee can be waived.

STEP 3: DRAFTING AND REVIEWING THE PETITION AND
ORDER
It’s finally time to start drafting your Petition and Order! Please take a look at the attached
sample petition, marked Appendix F.
For your current legal name, be sure write it exactly as it is written on your birth certificate. It is
very important to include an “A.K.A.” for any other name that appears on your official
documentation (such as the name you are incarcerated under, names that have appeared on your
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driver’s license or social security card, or names used in transacting business, etc.) You should
also include as A.K.A.’s different spellings of your name, like John Smith A.K.A. John A. Smith
A.K.A. John Andrew Smith, if these variations have been used in other documentation. If you
have previously received a legal name change, list your original name as an “F.K.A.” (formerly
known as) in addition to any A.K.A.’s. It’s important to know that you will not be able to change
your name successfully on other documentation if the current name is not listed as an A.K.A.
When you write down the name you want to legally use, make sure to include the full name
exactly as you wish it to be spelled. It can be helpful to inform the court of how you would like it
to look, such as “Jane (first) Marie (middle) Smith (last).” You can choose whatever name you
like, though courts have declined to grant name change orders to clients with less conventional
choices (for example, in Matter of Nawadiuko, the Civil Court in Richmond County denied a
petitioner family’s request to change their last name to ChristIsKing; Matter of Nawadiuko, 37
Misc. 3d 1207(A) (Civ Ct, Richmond County 2012)).
In answer to the reason for the name change, you can write anything you want, so long as it is
true for you. Many people choose to share information about their gender identity and transition
with the judge. However, it is also acceptable to simply state that you prefer the new name, use it
on a regular basis, and think it suits you better, so long as that is true. The reason doesn’t have to
be extensive or detailed, it only needs to be true for you and absent of any fraudulent or criminal
purpose.
There is also the matter of the requirement that Notice of the name change be published in a
newspaper. This requirement may be waived if publication would jeopardize your safety.
However, this exception can rarely be invoked for incarcerated people. If you are incarcerated
for a violent felony, then you will almost certainly be required to publish the Notice in your
county of incarceration (county of residence) and perhaps also in the county of conviction.
You must sign and verify the petition in front of a notary. All individuals in custody are entitled
to have access to a notary. Be sure you review a final copy of the petition and sign the
verification before you file it.

STEP 4: FILING THE PETITION, ORDER, AND INITIAL NOTICE
Name change proceedings must be filed in your county of residence. The only exception is when
you reside in New York City, in which case the petition may be filed in the Civil Court in any of
the five boroughs. The filing fee is $210 in most upstate counties (as of 2017), which is the cost
of purchasing an Index Number. Unfortunately, our experience is that the majority of counties
will not waive this filing fee. However, we have heard of one woman who was successful in
having her filing fee waived, therefore, it may be worthwhile to try. Please see Appendix H for
draft templates of how to waive filing fees.
If you are outside of New York City, you can file by mail in the Supreme Court in the County
where you are incarcerated. Usually you will mail the papers to the County Clerk; you can find a
list of the County Clerks in Appendix G.
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If you are not incarcerated for a conviction for a violent felony offense, you will mail the Index
Number fee ($210.00 payable to the County Clerk), the Petition, and the Order for filing to the
clerk. Usually you will need to send an original and two copies of each document. When you
send all of your paperwork and check to the Clerk, the Clerk will send you back an Index
Number. If you sent the Clerk an extra copy and a self-addressed envelope, they will also send
you your copy with the Index Number stamped on it.
You must select a return date, which should be at least 90 days from when you send out the
petition so that you are sure to have ample time to provide service on required parties.
If you are incarcerated for a violent felony offense, then your petition must state that you will be
responsible for serving notice to the interested parties upon receipt of the Index Number. These
parties include the District Attorney of every county in which you have been convicted of a
violent felony and the court or courts in which the sentence for each violent felony was entered.
Once you receive an Index Number, you must then make sure that the Notice of Petition is
served on the relevant parties. You cannot serve these papers yourself; you must ask someone
uninterested in the matter to do this for you. Many of our clients have been able to successfully
ask Jailhouse Lawyers, Law Clerks, or other trusted parties inside the prison to mail out the
paperwork on their behalf. Please see Appendix I for an example.
The Notice of Petition will have what is called a return date at least 60 days from the date of
service, according to the law. A return date is the date by which the Court is to make a decision
in a case.
After you ensure that the relevant parties were served by your third party, you must then send the
court an affidavit. This affidavit should be filled out by the third party and it must say that the
third party was served correctly. This must be notarized. Please see Appendix J for an example.
The return date will be a paper decision date only (more on this below). If the Judge wishes to
schedule a hearing, the Judge or their Clerk will contact you. You can also call the Clerk to
follow-up to determine if an in-person hearing will be necessary.

STEP 5: THE HEARING
The New York State Supreme Courts generally rule on name changes without having an inperson hearing. This is referred to as “on paper only.” It is extremely rare that you will have a
chance to make a formal oral argument, but it makes sense to have a short statement prepared in
case the judge wishes to hear you present the case. It is always possible that you will get a judge
who is unfamiliar with name changes involving transgender or incarcerated petitioners or who
misunderstands the law surrounding name changes and who will need to be educated. If you
have reviewed your submissions thoroughly and are familiar with the facts and the law, you will
be well prepared for the hearing. You should be prepared to answer questions briefly and
honestly. It is best to stick to the issue at hand, which is your name change, rather than to speak
about your conviction or whatever medical procedures you have had or have not had.
If you are serving a sentence for a violent felony or have a violent felony in your history, it is
possible that a district attorney could appear at these hearings. So far, in our experience, they

9

have never done so. Most often, district attorneys do not respond one way or the other to a name
change petition. On a couple of occasions, a district attorney has objected to a client’s request, on
the basis of potential record-keeping confusion. Case law states that confusion is often part of
any name change, and courts tend to hold that it is not a sufficient basis on which to deny name
change requests (a good example can be found with In re Powell, holding that “confusion is
attendant to any change of name and does not, in itself, justify denial.” In re Powell, 95 AD3d
1631, 1632 (3d Dept 2012)).

STEP 6: NOTICE AND PUBLICATION
After the name change has been granted, you will have to arrange for publication in a newspaper
and service on whichever parties the court identifies. Generally the Court will order you to
publish in a particular newspaper. Newspapers are accustomed to these requests and will know to
send you an affidavit of publication after the notice appears. You have 60 days from the date of
the order to complete service and publication and 90 days in which to file the proof. You file the
proof by sending to the court an affidavit of service (or certificate of mailing, whichever the
Court requests) and the affidavit of publication. If for some reason the time limits are exceeded,
it is possible to request nunc pro tunc relief, meaning that the court will retroactively amend the
previous ruling, extending the due date based on your submission date.

STEP 7: COMPLETION OF THE PROCESS
Congratulations! Once your name change is completed, you should request at least one certified
copy of the name change order from the clerk of the court. With most agencies, the certified
copy is the document that you will use in order to change your name.
Complications:
Name changes usually go smoothly, but particularly when you are an incarcerated transgender
person, complications may arise. Sometimes a judge will request some form of additional
documentation. If that happens, reach out to SRLP so we can provide you with the Jailhouse
Lawyers Manual chapter on legal writing. In addition, the prison law library might have NY civil
practice books that could be useful to you. If your name change is denied and you are unable to
appeal your case on your own, please reach out to SRLP to ask if we can take you on as an
emergency client.

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GLOSSARY
Affidavit: a written statement that is used as evidence in court. The truth of the contents of the
affidavit must be confirmed in front of a notary and the document must be notarized.
Certified Copy: a certified copy is a reproduction of a document that has been certified as accurate by the agency that produces the document. For name changes, certified copies almost always
have a raised seal from the court that lets government agencies know that it is more than a photocopy, it is a copy certified by the Clerk of the Court as being accurate and complete.
Exhibits: a document or other object produced for the court. Sometimes, a fancy exhibit tab is
used; however, it is fine to simply write Exhibit A on a blank piece of paper prior to the exhibit
itself.
Index Number: a number issued by the county clerk, which is used to identify a case. Index
Numbers must be purchased from the county clerk.
Notice of Petition: written notice delivered to whomever is responding or opposing the case informing them of when the court will hear the attached petition so that the responding or opposing
party is informed of the deadline.
Nunc Pro Tunc: a Latin expression that is used in legal circles to mean that a Judge’s order can
apply after the fact to correct an earlier ruling. Generally, Judge’s rulings only apply to cases going forward, a nunc pro tunc ruling is unusual as it applies to previous decisions.
Order: an oral or written command or a direction from a judge.
Petition: a written document filed in court which states what the individual submitting the petition (the petitioner) is requesting from the court.
Return Date: the date when the response to a petition or other court paper must be made.
Statute: a written law passed by a legislative body. A New York State statute refers to a law
passed by the New York State legislature and signed into law by the New York governor. These
laws govern or control behavior and the legally correct way to do certain things.

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Appendix A: Article 6: Civil Rights: Change of Name

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New York State Consolidated Laws: Civil Rights
ARTICLE 6 CHANGE OF NAME
Section 60. Petition for change of name.
61. Contents.
62. Notice.
63. Order.
64. Effect.
64-a. Exemption from publication requirements.
65. Optional change of name upon marriage, divorce or annulment.
§ 60. Petition for change of name.
A petition for leave to assume another name may be made by a resident of the state to the county
court of the county or the supreme court in the county in which he resides, or, if he resides in the
city of New York, either to the supreme court or to any branch of the civil court of the city of
New York, in any county of the city of New York. The petition to change the name of an infant
may be made by the infant through his next friend, or by either of his parents, or by his general
guardian, or by the guardian of his person.
§ 61. Contents
1. The petition shall be in writing, signed by the petitioner and verified in like manner as a
pleading in a court of record, and shall specify the grounds of the application, the name, date
of birth, place of birth, age and residence of the individual whose name is proposed to be
changed and the name which he or she proposes to assume. The petition shall also specify (a)
whether or not the petitioner has been convicted of a crime or adjudicated a bankrupt; (b)
whether or not there are any judgments or liens of record against the petitioner or actions or
proceedings pending to which the petitioner is a party, and, if so, the petitioner shall give descriptive details in connection therewith sufficient to readily identify the matter referred to; (c)
whether or not the petitioner is responsible for child support obligations; (d) whether or not
the petitioner's child support obligations have been satisfied and are up to date; (e) the amount
of a child support arrearage that currently is outstanding along with the identity of the court
which issued the support order and the county child support collections unit; (f) whether or
not the petitioner is responsible for spousal support obligations; (g) whether or not the petitioner's spousal support obligations have been satisfied and are up to date; and (h) the amount
of spousal support arrearage that currently is outstanding along with the identity of the court
which issued the support order.
2. If the petitioner stands convicted of a violent felony offense as defined in section 70.02 of the
penal law or a felony defined in article one hundred twenty-five of such law or any of the following provisions of such law sections 130.25, 130.30, 130.40, 130.45, 255.25, 255.26,
255.27, article two hundred sixty-three, 135.10, 135.25, 230.05, 230.06, subdivision two of
section 230.30 or 230.32, and is currently confined as an inmate in any correctional facility or
currently under the supervision of the state division of parole or a county probation department as a result of such conviction, the petition shall for each such conviction specify such
felony conviction, the date of such conviction or convictions, and the court in which such

13

conviction or convictions were entered.
3. Upon all applications for change of name by persons born in the state of New York, there
shall be annexed to such petition either a birth certificate or a certified transcript thereof or a
certificate of the commissioner or local board of health that none is available.
§ 62. Notice
1. If the petition be to change the name of an infant, notice of the time and place when and where
the petition will be presented must be served, in like manner as a notice of a motion upon an
attorney in an action, upon (a) both parents of the infant, if they be living, unless the petition
be made by one of the parents, in which case notice must be served upon the other, if he or she
be living, and (b) the general guardian or guardian of the person, if there be one. But if any of
the persons, required to be given notice by this section, reside without the state, then the notice
required by this section must be sent by registered mail to the last known address of the person
to be served. If it appears to the satisfaction of the court that a person required to be given notice by this section cannot be located with due diligence within the state, and that such person
has no known address without the state, then the court may dispense with notice or require notice to be given to such persons and in such manner as the court thinks proper.
2. If the petition be to change the name of a person currently confined as an inmate in any correctional facility or currently under the supervision of the state division of parole or a county
probation department as a result of a conviction for a violent felony offense as defined in section 70.02 of the penal law or a felony defined in article one hundred twenty-five of such law
or any of the following provisions of such law sections 130.25, 130.30, 130.40, 130.45,
255.25, 255.26, 255.27, article two hundred sixty-three, 135.10, 135.25, 230.05, 230.06, subdivision two of section 230.30 or 230.32, notice of the time and place when and where the petition will be presented shall be served, in like manner as a notice of a motion upon an attorney in an action, upon the district attorney of every county in which such person has been
convicted of such felony and upon the court or courts in which the sentence for such felony
was entered. Unless a shorter period of time is ordered by the court, said notice shall be served
upon each such district attorney and court or courts not less than sixty days prior to the date on
which such petition is noticed to be heard.
§ 63. Order
If the court to which the petition is presented is satisfied thereby, or by the affidavit and certificate presented therewith, that the petition is true, and that there is no reasonable objection to the
change of name proposed, and if the petition be to change the name of an infant, that the interests
of the infant will be substantially promoted by the change, the court shall make an order authorizing the petitioner to assume the name proposed. The order shall further recite the date and
place of birth of the applicant and, if the applicant was born in the state of New York, such order
shall set forth the number of his birth certificate or that no birth certificate is available. The order
shall be directed to be entered and the papers on which it was granted to be filed prior to the publication hereinafter directed in the clerk's office of the county in which the petitioner resides if he
be an individual, or in the office of the clerk of the civil court of the city of New York if the order be made by that court. Such order shall also direct the publication, at least once, within sixty
days after the making of the order, in a designated newspaper in the county in which the order is

14

directed to be entered and if the petition is made by a person subject to the provisions of subdivision two of section sixty-two of this article, in a designated newspaper in any county wherein
such person was convicted if different from the county in which the order is otherwise directed to
be entered, of a notice in substantially the following form: Notice is hereby given that an order
entered by the............ court,............ county, on the...... day of......., bearing Index Number...........,
a copy of which may be examined at the office of the clerk, located at................., in room number......., grants me the right to assume the name of................... My present address
is.........................; the date of my birth is...............; the place of my birth is....................; my present name is................................
§ 64. Effect
If the order shall be fully complied with, and within ninety days after the making of the order, an
affidavit of the publication thereof shall be filed in the office in which the order is entered, the
petitioner shall be known by the name which is thereby authorized to be assumed. If the surname
of a parent be changed as provided in this article, any minor child of such parent at the time of
such change may thereafter assume such changed surname.
Upon compliance with the order and the filing of the affidavit of the publication, as provided in
this section, the clerk of the court in which the order has been entered shall certify that the order
has been complied with; and, if the petition states that the petitioner stands convicted of a violent
felony offense as defined in section 70.02 of the penal law or a felony defined in article one hundred twenty-five of such law or any of the following provisions of such law sections 130.25,
130.30, 130.40, 130.45, 255.25, 255.26, 255.27, article two hundred sixty-three, 135.10, 135.25,
230.05, 230.06, subdivision two of section 230.30 or 230.32, such clerk (1) shall deliver, by first
class mail, a copy of such certified order to the division of criminal justice services at its office in
the county of Albany and (2) upon the clerk of the court reviewing the petitioner's application for
name change and subsequent in-court inquiry, may, in the clerk's discretion, deliver, by first
class mail, the petitioner's new name with such certified order to the court of competent jurisdiction which imposed the orders of support. Such certification shall appear on the original order
and on any certified copy thereof and shall be entered in the clerk's minutes of the proceeding.
§ 64-a. Exemption from publication requirements.
1. If the court shall find that the publication of an applicant's change of name would jeopardize
such applicant's personal safety, the provisions of sections sixty-three and sixty-four of this article requiring publication shall be waived and shall be inapplicable. The court shall order the
records of such change of name proceeding to be sealed, to be opened only by order of the
court for good cause shown or at the request of the applicant.
2. Notwithstanding any other provision of law, pending such a finding in subdivision one where
an applicant seeks relief under this section, the court shall immediately order the applicant's
current name, proposed new name, residential and business addresses, telephone numbers, and
any other information contained in any pleadings or papers submitted to the court to be safeguarded and sealed in order to prevent their inadvertent or unauthorized use or disclosure
while the matter is pending.
§ 65. Optional change of name upon marriage, divorce or annulment.

15

1. Any person may, upon marriage, elect to assume a new name according to the provisions of
paragraph (b) of subdivision one of section fifteen of the domestic relations law.
2. Any person may, upon divorce or annulment, elect to resume the use of a former surname according to the provisions of section two hundred forty-a of the domestic relations law.
3. The effect of the name changes accomplished in the manner prescribed in subdivisions one
and two of this section shall be as set forth in section sixty-four of this chapter.
4. Nothing in this article shall be construed to abrogate or alter the common law right of every
person, whether married or single, to retain his or her name or to assume a new one so long as
the new name is used consistently and without intent to defraud.
5. Notwithstanding any inconsistent provision of law, the state shall not impose any fee, charge,
surcharge or assessment solely to change the surname contained on a license, permit, registration or other identifying document for a person who, because of a change in marital status, has
assumed a new name or reassumes use of a former surname as provided for in this section.

16

Appendix B: Name Change Questions

17

Name Change Questionnaire
This questionnaire will help you put together everything needed in order to prepare your name
change.
FULL Birth name (Exactly as on your Birth Certificate):
_____________________________________________________________________________
Name you wish to change to:
_____________________________________________________________________________
Names on other identification (and AKAs):
_____________________________________________________________________________
Date and place of birth:
_____________________________________________________________________________
What is your current address?
_____________________________________________________________________________
Do you have your Birth Certificate?: _Y / N_
Birth Certificate #_______________________________________________________________
If not, do you have a Passport (if so, from where?) _____________________________________
Have you ever been married?: _Y / N_
If so, are you responsible for spousal support?: _Y / N_
If yes, where was the support ordered?:______________________________________________
Are you responsible for child support?: _Y / N_
If yes, where was the support ordered?:______________________________________________
Criminal Convictions:
_____________________________________________________________________________
_____________________________________________________________________________

18

Conviction for which you are presently incarcerated:
_____________________________________________________________________________
_____________________________________________________________________________
Are any of these convictions violent felonies as defined by NY Penal Law 70.02?:
_____________________________________________________________________________
_____________________________________________________________________________
Are there any judgments or liens against you (this generally refers to money that a Judge or another government body has determined you owe)?:
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever been declared bankrupt?: _Y / N_
If yes, where was your bankruptcy declared?:_________________________________________
Are you currently a party to any court case or action (a 1983 claim, etc.)?:
_____________________________________________________________________________
_____________________________________________________________________________
In your own words, why do you want to change your name:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Name Change cases require publication of your old and new name as well as other information
including your address in one or more newspapers. It is often very hard to waive this requirement
for someone incarcerated. However, this may be possible if you have fear of a specific person
finding out, such as someone who has hurt you in the past, threatened to hurt you, or is currently

19

harming you. Are you afraid that a specific person or people will find out?:
_____________________________________________________________________________
_____________________________________________________________________________

Do you have any paperwork or other evidence of this fear that you could bring to a Judge?:
_____________________________________________________________________________
_____________________________________________________________________________

20

Appendix C: New York Penal Law § 70.02

21

New York Penal Law § 70.02 Sentence of imprisonment for a violent felony offense
1. Definition of a violent felony offense. A violent felony offense is a class B violent felony
offense, a class C violent felony offense, a class D violent felony offense, or a class E violent
felony offense, defined as follows:
(a) Class B violent felony offenses:  an attempt to commit the class A-I felonies of murder in the
second degree as defined in section 125.25, kidnapping in the first degree as defined in section
135.25, and arson in the first degree as defined in section 150.20;  manslaughter in the first degree as defined in section 125.20, aggravated manslaughter in the first degree as defined in section 125.22, rape in the first degree as defined in section 130.35, criminal sexual act in the first
degree as defined in section 130.50, aggravated sexual abuse in the first degree as defined in section 130.70, course of sexual conduct against a child in the first degree as defined in section
130.75;  assault in the first degree as defined in section 120.10, kidnapping in the second degree
as defined in section 135.20, burglary in the first degree as defined in section 140.30, arson in the
second degree as defined in section 150.15, robbery in the first degree as defined in section
160.15, incest in the first degree as defined in section 255.27, criminal possession of a weapon in
the first degree as defined in section 265.04, criminal use of a firearm in the first degree as defined in section 265.09, criminal sale of a firearm in the first degree as defined in section 265.13,
aggravated assault upon a police officer or a peace officer as defined in section 120.11, gang assault in the first degree as defined in section 120.07, intimidating a victim or witness in the first
degree as defined in section 215.17, hindering prosecution of terrorism in the first degree as defined in section 490.35, criminal possession of a chemical weapon or biological weapon in the
second degree as defined in section 490.40, and criminal use of a chemical weapon or biological
weapon in the third degree as defined in section 490.47.
(b) Class C violent felony offenses:  an attempt to commit any of the class B felonies set forth in
paragraph (a) of this subdivision;  aggravated criminally negligent homicide as defined in section
125.11, aggravated manslaughter in the second degree as defined in section 125.21, aggravated
sexual abuse in the second degree as defined in section 130.67, assault on a peace officer, police
officer, fireman or emergency medical services professional as defined in section 120.08, assault
on a judge as defined in section 120.09, gang assault in the second degree as defined in section
120.06, strangulation in the first degree as defined in section 121.13, burglary in the second degree as defined in section 140.25, robbery in the second degree as defined in section 160.10,
criminal possession of a weapon in the second degree as defined in section 265.03, criminal use
of a firearm in the second degree as defined in section 265.08, criminal sale of a firearm in the
second degree as defined in section 265.12, criminal sale of a firearm with the aid of a minor as
defined in section 265.14, aggravated criminal possession of a weapon as defined in section
265.19, soliciting or providing support for an act of terrorism in the first degree as defined in section 490.15, hindering prosecution of terrorism in the second degree as defined in section 490.30,
and criminal possession of a chemical weapon or biological weapon in the third degree as defined in section 490.37.
(c) Class D violent felony offenses:  an attempt to commit any of the class C felonies set forth in
paragraph (b);  reckless assault of a child as defined in section 120.02, assault in the second degree as defined in section 120.05, menacing a police officer or peace officer as defined in section

22

120.18, stalking in the first degree, as defined in subdivision one of section 120.60, strangulation
in the second degree as defined in section 121.12, rape in the second degree as defined in section
130.30, criminal sexual act in the second degree as defined in section 130.45, sexual abuse in the
first degree as defined in section 130.65, course of sexual conduct against a child in the second
degree as defined in section 130.80, aggravated sexual abuse in the third degree as defined in
section 130.66, facilitating a sex offense with a controlled substance as defined in section 130.90,
criminal possession of a weapon in the third degree as defined in subdivision five, six, seven,
eight, nine or ten of section 265.02, criminal sale of a firearm in the third degree as defined in
section 265.11, intimidating a victim or witness in the second degree as defined in section
215.16, soliciting or providing support for an act of terrorism in the second degree as defined in
section 490.10, and making a terroristic threat as defined in section 490.20, falsely reporting an
incident in the first degree as defined in section 240.60, placing a false bomb or hazardous substance in the first degree as defined in section 240.62, placing a false bomb or hazardous substance in a sports stadium or arena, mass transportation facility or enclosed shopping mall as defined in section 240.63, and aggravated unpermitted use of indoor pyrotechnics in the first degree
as defined in section 405.18.
(d) Class E violent felony offenses:  an attempt to commit any of the felonies of criminal possession of a weapon in the third degree as defined in subdivision five, six, seven or eight of section
265.02 as a lesser included offense of that section as defined in section 220.20 of the criminal
procedure law, persistent sexual abuse as defined in section 130.53, aggravated sexual abuse in
the fourth degree as defined in section 130.65-a, falsely reporting an incident in the second degree as defined in section 240.55 and placing a false bomb or hazardous substance in the second
degree as defined in section 240.61.

23

Appendix D: NYC Birth Certificate

24

Register to vote:
http://www.nyccfb.info/public/VRC/registeringToVote.aspx?sm=public rtv

Office of Vital Records
125 Worth Street, CN-4, Room 133
New York, N.Y. 10013-4090
SEE INSTRUCTIONS AND
APPLICABLE FEES BELOW AND
ON BACK

BIRTH CERTIFICATE APPLICATION
(Please Print Clearly)
1. LAST NAME ON BIRTH CERTIFICATE

2. FIRST NAME

3.

Ⅺ

FEMALE

Ⅺ
4a. IF YOU KNOW THE EXACT DATE OF BIRTH

MM

DD

4b. IF YOU DON’T KNOW THE EXACT DATE OF BIRTH
BEGIN
END
SEARCH
SEARCH

YYYY

MM

DD

YYYY

MM

5. NAME OF HOSPITAL OR ADDRESS WHERE BORN

YYYY

SEE BELOW
FOR FEE
INFORMATION

6. BOROUGH WHERE BORN
MAN Ⅺ

7. MOTHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE (MAIDEN NAME):
FIRST

DD

MALE

BRONX Ⅺ

BKLYN Ⅺ

QUEENS Ⅺ

SI Ⅺ

8. BIRTH CERTIFICATE NUMBER (if known)

LAST

9. FATHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE
FIRST

10. WHY DO YOU NEED THIS BIRTH CERTIFICATE

LAST

11. DO YOU NEED A LETTER
OF EXEMPLIFICATION?
Ⅺ YES Ⅺ NO

12. HOW MANY COPIES
DO YOU NEED?
1Ⅺ 2Ⅺ 3Ⅺ

13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE?
SELF/PARENT/OTHER (please explain)

PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
NAME
STREET ADDRESS

APT. NO.

CITY

STATE

ZIP CODE

DAYTIME
PHONE
NUMBER

Area Code

Telephone Number

E-MAIL
ADDRESS

NOTE: Copy of a birth record can be issued only to persons to whom the record of birth relates, if of age, or to a parent or human
service organizations. It is a violation of law to make a false, untrue or misleading statement or forge the signature of another on this
application. Violations are a misdemeanor punishable by a fine of up to $2,000.
15. CUSTOMER COMMENTS/ADDITIONAL INFORMATION

14. CUSTOMER SIGNATURE AND DATE

SIGNATURE:

DATE:

APPLICATIONS SUBMITTED BY MAIL MUST
BE NOTARIZED

FEES
$15 per copy x _________ copies

NOTARY PUBLIC SEAL

$ ________
STATE OF

Cost of certified copy includes a two consecutive
year search

COUNTY OF

$3 for each extra year searched x ________ years $ ________

SUBSCRIBED AND SWORN BEFORE ME:

Total Amount Enclosed: $ ________
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT”
WILL BE ISSUED. CASH IS NOT ACCEPTED BY MAIL OR IN PERSON.

THIS ______ DAY OF _______________ , 20 ____

NOTARY PUBLIC SIGNATURE

ORDER BIRTH CERTIFICATES QUICKLY AND SECURELY AT WWW.NYC.GOV/VITALRECORDS
VR 67 (Rev. 10/14)

IMPORTANT BIRTH CERTIFICATE INFORMATION
‚ You can obtain a birth certificate for yourself if you are at least 18 years old, or for your child, with current

identification. Detailed instructions for attorneys submitting requests on behalf of their clients are available
online at www.nyc.gov/vitalrecords.

‚ Falsifying information, including forging a signature, to obtain a birth certificate is a misdemeanor and violators
may also be subject to a fine of up to $2,000 per violation.

‚ Credit cards are not accepted for mail-in orders. If from a foreign country, send an international money order.
‚ Please allow 10–15 days processing time for all long form/vault certificate orders submitted in person.
‚ Processing of mailed applications takes approximately 15 days. Check current times at www.nyc.gov/vitalrecords.
3 WAYS TO ORDER A NEW YORK CITY BIRTH CERTIFICATE
l

Online: Visit www.nyc.gov/vitalrecords to order using a credit card, debit card, or electronic check.
Online orders are processed within 24 hours on weekdays, and UPS express mail delivery is available.

l

Walk-In: Go to 125 Worth Street in Lower Manhattan and use the Lafayette Street (handicapped accessible) or
Centre Street entrances. We are open Monday through Friday 9:00AM – 3:30PM. Lines are shortest in the morning.
Please see identification requirements below.

l

By Mail: All mailed applications must be notarized. Mail your application to 125 Worth Street, CN-4, New York,
NY 10013. Be sure to include a self-addressed, stamped, envelope with your check or money order payable
to the NYC Department of Health and Mental Hygiene. You must provide a photocopy of Category 1
identification or original copies of identification from Category 2 (see below).

Identification (ID) Requirements to get a Birth Certificate for you or your child.
Category 1: Identity documents. If you order in person you can leave with your short form certificate in most
cases, unless you require a long form certificate.
Provide any of the following, if it includes your photo, your signature and is unexpired:
l
l
l
l
l
l
l
l
l

Driver’s License or non-driver’s ID from any state or U.S. territory
Public benefit card
U.S. or foreign passport
U.S. certificate of naturalization
Military ID card
Employee ID with photo, verifiable employer and recent pay stub
MTA reduced-fare Metro Card
Student ID and current transcript from accredited and verifiable institution
Inmate photo ID with release papers

Category 2: Proof of address. If you do not have any of the above, you may provide proof of address as described
below. Your certificate will be mailed to address on documents provided.
Two different documents dated within the past 60 days, if they show your name and address
l
Utility bills (online bills can be downloaded from your provider)
l
Letter from a government agency
If you cannot provide Category 1 or 2 identification, please contact Vital Records at nycdohvr@health.nyc.gov.

VR 67 (Rev. 10/14)

Appendix E: NYS Birth Certificate Request

26

NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section

Mail-in Application for Copy of Birth Certificate

Information Page ߞ Mail-in Application for Copy of Birth Certificate
General Instructions
ߦ Do not use this application to submit your request by fax.
ߦ Use this application only if you are the person named on the birth certificate or that persons parents.
ߦ Use this application only if the birth occurred in New York State outside of New York City. Do not use this
application if the birth occurred in any of the five (5) boroughs of New York City.
ߦ Do not use this application for genealogy requests.
ߦ Print a copy of this application, complete and sign.
ߦ Mail application along with check or money order and a copy of the required documentation (see below).
For regular handling send by first class mail, registered
mail, certified mail or U.S. Priority Mail to:
Certification Unit
Vital Records Section
New York State Department of Health
P.O. Box 2602
Albany, NY 12220-2602

For priority handling (add $15.00 per copy ordered),
submission by overnight carrier is recommended. Send to:
Certification Unit
Vital Records Section / 2nd Floor
New York State Department of Health
800 North Pearl Street
Menands, NY 12204

Identification Requirements: Application must be submitted with copies of either A or B:
Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.
A. One (1) of the following forms of valid photo-ID:
ߦ Driver license
ߦ Non-driver license
ߦ Passport
ߦ Other government issued photo-ID
B. Two (2) of the following showing the applicants name and address:
ߦ Utility bill or telephone bill
ߦ Letter from a government agency dated within the last six (6) months
Fees: If no record is on file, a No Record Certification is issued and the fee is not refunded.
ߦ For regular handling: The fee is $30.00 per copy. ߞ Total for one (1) copy is $30.00. Total for two (2) copies is
$60.00, etc.
ߦ For priority handling: The fee is $30.00 + $15.00 per copy. ߞ Total for one (1) copy is $45.00. Total for two (2)
copies is $90.00, etc. Submitting the application by overnight carrier is recommended. Completed requests will be
returned by first class mail unless a pre-paid return mailer for overnight delivery is provided with the request.
ߦ Send check or money order payable to the New York State Department of Health. Do not send cash.
Note: Payment submitted from foreign countries must be made by a check drawn on a United States bank or by
international money order. Do not send cash.
Processing Time
ߦ For the latest information on processing times, please visit our web page at
www.nyhealth.gov/vital_records/processingtime.htm
ߦ For faster processing, you may wish to use your credit card and submit your request by e-mail, fax, or telephone.
Completing the Form
ߦ If you are using Adobe Reader ® 5.0 or newer (available as a free download from www.adobe.com) you can fill in the
form directly in Adobe Reader by clicking on the appropriate space and entering the information (use the TAB key to
move to the next field, shift-TAB to move backwards). Print the completed form, sign and mail to the above address.
ߦ You can print out a blank copy of the form and then type or print the required information.
ߦ Be sure to sign the form before mailing and include a check or money order made payable to the New York State
Department of Health along with copies of the required identification.
DOH-4380 (12/05) Page 1 of 2

NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section

Mail-in Application for Copy of Birth Certificate

Required ID must be included with application. Make check or money order payable to New York State Department of Health.
For regular handling: Enclose $30 per copy or No Record Certification. For priority handling: Enclose $45 per copy or No Record Certification.
Send to:
Submission by overnight carrier is recommended. Send to:
New York State Department of Health
New York State Department of Health
Vital Records Section / Certification Unit
Vital Records Section / Certification Unit
800 North Pearl Street - 2nd Floor
P.O. Box 2602
Menands, NY 12204
Albany, NY 12220-2602
Name: (as listed on birth certificate)
Date of Birth:

First

Town, city or village where birth occurred:

Middle

(mm / dd / yyyy)

Last

Name of hospital where birth occurred: (If known)

Maiden Name of Mother: (as listed on birth certificate)

Birth Certificate No.:
(If known)

Local Registration No.:
First

Middle

(If known)

Maiden Last

Father: (as listed on birth certificate)
Number of Copies Requested:

First

Middle

Purpose for which
Record is Required:
(Check one)

Passport
Social Security
Retirement
Other (specify)

What is your relationship to person whose
record is required? (If self, state "SELF".)

Standard Size:

Last

Employment
Working Papers
School entrance

Drivers license
Marriage license
Welfare assistance

Wallet Size:

Veterans benefits
Court proceeding
Entrance into
Armed Forces

If attorney, give name and relationship of your client to person whose record is required:

This office requires written authorization of the person/parents whose record is requested.
Date Signed:

Signature of Applicant:

Month

Day

Year

Regular Handling
(Check Only One)

J

Priority Handling

$30.00 x
OR
$45.00 x

Copies

=

$

Please print or type the name and address where record
should be sent: (If delivery is to a P.O. Box or third party, you must submit

Address of Applicant:

with this application a notarized statement signed by the applicant and a copy of
the applicants drivers license.)

(Applicants Name)

(Name)
(Street)

(City)

Telephone No.: (

(State)

(Zip)

(Street)

)
(City)

DOH-4380 (12/05) Page 2 of 2

(State)

(Zip)

Appendix F: Sample Petition and Sample Order

28

Supreme Court of the State of New York
County of _______
------------------------------------------------------------------------x
In the Matter of the Application of
|
|
PETITION FOR
|
__________________________
|
CHANGE OF NAME
|
|
for Leave to Assume the Name of
|
|
_________________________
|
|
------------------------------------------------------------------------x

PETITION FOR
INDIVIDUAL ADULT
CHANGE OF NAME
Index No. ________

_________________________, by this petition, alleges:
1.

Petitioner’s present name is _________________________.

2.

The name which Petitioner proposes to assume in place and stead of the present
name is _________________________.

3.

Petitioner was born on _________________________ in
_________________________. A copy of petitioner’s birth certificate, Certificate
Number _________________________ is attached as Exhibit A.

4.

Petitioner currently resides at _________________________.

5.

Petitioner is ____ responsible for spousal support.

6.

Petitioner has _____ minor children and _____ obligations for child support.

7.

a) [if you have a violent felony charge] Petitioner has been convicted of a crime
that falls under the definition of violent felony under New York Penal Law Sec.
70.02. Petitioner is currently incarcerated at _________________________. Petitioner’s DIN number is _________________________. Petitioner was convicted
of ___(name and penal law code for conviction)__________under docket number _________________________on ______(date)____________ in
_________________________ County, New York. A complete copy of Petitioner’s criminal history in New York is attached as Exhibit B. Upon notification of
an index number and return date for this petition, Petitioner agrees to serve notice
of such motion upon the district attorney in _________________________ County, New York in addition to the court of conviction in compliance with Civil
Rights Law § 62.2
[if you do NOT have a violent felony charge] Petitioner has not been convicted
of a crime that falls under the definition of violent felony under New York Penal

29

Law Sec. 70.02. Petitioner is currently incarcerated at
_________________________. Petitioner’s DIN number is
_________________________. A complete copy of Petitioner’s criminal history
in New York is attached as Exhibit B.
b)
c)

Petitioner has never been adjudicated bankrupt.
There are no judgments or liens of record against Petitioner.

8.

Petitioner has not made a previous application to change their name in this or any
other Court.

9.

The grounds for this application are as follows: _________________________

10.

Should the Court find this petition deficient in any aspect, Petitioner respectfully
requests leave to renew the application with additional information as the Court
may require.

WHEREFORE, your petitioner respectfully prays that an Order be granted permitting this
requested change of name.

DATED:

_________________________

SIGNED:

___________________________

30

VERIFICATION
State of New York

}
} ss::
County of _________}
_________________________, being duly sworn, says that I am the Petitioner named above,
that I have read the petition and know the truth of the contents thereof except for matters alleged
to be on information and belief, and as to those matters, I believe them to be true.

__________________________________
YOUR NAME

Sworn to before me this
____ day of ____________, 2017

____________________________________
Notary Public

31

(Please review this form carefully. You need only fill out the sections where it says “fill out”
– the sections that are left blank are for the Judge or Clerk to fill out at the right time.)
At a ______ Term, Part ____of the
_______ Court of the State of New
York, held in and for the County of
_____, New York on the ___ day of
______ , 2017

PRESENT: HON. _____________________

Supreme Court of the State of New York
County of ______
------------------------------------------------------------------------x
In the Matter of the Application of
|
|
PETITION FOR
|
___”fill out”_______________________
|
CHANGE OF NAME
|
|
for Leave to Assume the Name of
|
|
___”fill out”___________________
|
|
------------------------------------------------------------------------x

NAME CHANGE ORDER

Index No. ________

Upon the annexed Petition of ___”fill out”_______ A.K.A. ___”fill out”_______ verified
on the ___”fill out”_______ day of ___”fill out”_______ 2017, requesting that petitioner be
permitted to assume the name of ___”fill out”_______ , and the Court being satisfied that the
Petition is true, and it appearing from the Petition that and the Court being satisfied that there is
no reasonable objection to the change of name proposed, it is hereby ORDERED that:
1. The individual currently known as ___”fill out”_______ A.K.A. ___”fill
out”_______, who was born on ___”fill out”_______ in ___”fill out”_______ with
Birth Certificate Number ___”fill out”_______ is hereby authorized to assume the
name of ___”fill out”_______ in place and stead of petitioner’s present name upon
complying with the provisions of Article 6 of the Civil Rights Law and of this Order.

32

2. This Order, consisting of a total of __________ pages, shall be entered, and the Petition upon which it was granted shall be filed, prior to the publication hereinafter directed, in the
office of the Clerk of __________ County.
3. ORDERED that at least sixty days after the entry of this Order, a copy of this Order
and supporting documentation shall be served upon: the district attorney in __________ County,
New York, in compliance with Civil Rights Law § 62.2 and the Court in which the petitioner
was convicted, __________, New York.
4. ORDERED that proof of service upon the above indicated parties shall be filed with
the Clerk of this Court within ninety days of the date of entry of this Order.
5. ORDERED that there is at least once within sixty days after the making of this Order,
prescribed by article 6 of the Civil Rights Law of the State of New York shall be published in the
_________ , a newspaper published in said County of ___________. Publication shall consist of
the following text:
Notice is hereby given that an order entered by the ___________ court,
___________ county, on the ____ day of ____, 2017 bearing Index Number
___________, a copy of which may be examined at the office of the clerk,
located at ___________ in room number _____, grants me the right to assume
the name of ___”fill out”_______ My present address is ___”fill
out”_______ the date of
my birth is ___”fill out”_______ ; the
place of my birth is ___”fill out”_______ ; my present name is ___”fill
out”_______.
6. ORDERED that proof of publication as heretofore directed shall be filed in the office
of the __________ County Clerk within 90 days after the signing of this order.
7. Following the filing of the Petition and the entry of this Order as directed in Paragraph 2 above, the service, if any, of such Order and such papers as directed in Paragraph 3
above, the filing of proof of such service as directed in Paragraph 4 above, it is further ORDERED that:

33

Petitioner, ___”fill out”_______ A.K.A. ___”fill out”_______ shall be known as and by
the name of ___”fill out”_______ which petitioner is hereby authorized to assume.

ENTER
__________________
Date

___________________________
Judge, Civil Court

34

Appendix G: List of NYS County Clerks

35

Albany County:
Albany County Court House, Room 128
16 Eagle Street, Albany, NY 12207-1077
Allegany County:
7 Court Street, Room 18
Belmont, NY 14813
Bronx County:
851 Grand Concourse, Room 118
Bronx, NY 10451
Broome County:
Richard R. Blythe
Department of Records
Broome County Office Building
60 Hawley Street, 3rd Floor
PO Box 2062
Binghamton, NY 13902-2062
Cattaraugus County:
Cattaraugus County Clerk’s Office
Cattaraugus County Center
303 Court Street
Little Valley, NY 14755
Cayuga County:
160 Genesee Street, 1st Floor
Auburn, NY 13021
Chautauqua County:
Larry Barmore, County Clerk
1 N. Erie Street
P.O. Box 170
Mayville, NY 14757
Chemung County:
210 Lake Street
P.O. Box 588
Elmira, NY 14902-0588
Chenango County:
5 Court Street
Norwich, NY 13815

Clinton County:
Clinton County Government Center
137 Margaret Street
Plattsburgh, NY 12901
Columbia County:
Columbia County Clerk
Holly C. Tanner
560 Warren Street
Hudson, NY 12534
Cortland County:
46 Greenbush Street, Suite 105
Cortland, NY 13045
Delaware County:
PO Box 426
Delhi, NY 13753
Dutchess County:
Receiving Department, 1st Floor
22 Market Street
Poughkeepsie, NY 12601
Erie County:
92 Franklin Street
Buffalo, NY 14202
Essex County:
7559 Court Street
Elizabethtown, NY 12932
Franklin County:
Kip Cassavaw, County Clerk
P.O. Box 70
355 West Main Street, Suite 248
Malone, NY 12953
Fulton County:
Fulton County Office Building
223 West Main Street
Johnstown, NY 12095

36

Genesee County:
Genesee County Clerk
CO. BLDG. #1, P.O. Box 379
Batavia, NY 14021-0379

Monroe County:
101 County Office Building
39 W. Main Street
Rochester, NY 14614

Greene County:
411 Main Street
Catskill, NY 12414

Montgomery County:
Montgomery County Office Building
P.O. BOX 1500 – 64 Broadway
Fonda, NY 12068-1500

Hamilton County:
102 County View Drive
P.O. Box 204
Lake Pleasant, NY 12108
Herkimer County:
Sylvia M. Rowan
Herkimer County Clerk
109 Mary Street, Suite 1111
Herkimer, NY 13350-2923
Jefferson County:
175 Arsenal Street
Watertown, NY 13601
Kings County (Brooklyn):
The Kings County Clerk Supreme Court
Building
360 Adams Street
Room 189
Brooklyn, NY 11201
Lewis County:
Lewis County Court House
PO Box 232
7660 N. State Street
Lowville, NY 13367

Nassau County:
240 Old Country Road
Mineola, NY 11501
New York County (Manhattan):
New York County Courthouse
60 Centre Street, Room 161
New York, NY 10007
Niagara County:
Niagara County Courthouse
P.O. Box 461
175 Hawley Street, 1st Floor
Lockport, NY 14095-0461
Oneida County:
Sandra J. DePerno
Oneida County Clerk
Oneida County Office Building
800 Park Avenue
Utica, NY 13501
Onondaga County:
Onondaga County Clerk
401 Montgomery Street
Room 200
Syracuse, NY 13202

Livingston County:
Livingston County Government Center
6 Court Street, Room 201
Geneseo, NY 14454

Ontario County:
20 Ontario Street
Canandaigua, NY 14424

Madison County:
138 N. Court Street
Building #4
Wampsville, NY 13163

Orange County:
Parry Building
4 Glenmere Cove Road
Goshen, NY 10924

37

Orleans County:
Karen Lake-Maynard, County Clerk
3 South Main Street, Suite 1
Courthouse Square
Albion, NY 14411
Oswego County:
46 East Bridge Street
Oswego, NY 13126
Otsego County:
197 Main Street
Cooperstown, NY 11326
Putnam County:
Putnam County Office Building
40 Gleneida Avenue, Room 100
Carmel, NY 10512
Queens County:
8811 Sutphin Blvd, #105
Jamaica, NY 11435
Rensselaer County:
105 Third Street
Troy, NY 12180
Richmond County (Staten Island):
130 Stuyvesant Place, 2nd Floor
Staten Island, NY 10301
Rockland County:
Rockland County Courthouse
1 South Main Street, Suite 100
New City, NY 10956-3549

Schenectady County:
620 State Street
Schenectady, NY 12305
Schoharie County:
284 Main Street
Schoharie, NY 12157
Schuyler County:
105 Ninth Street
Unit 8
Watkins Glen, NY 14891
Seneca County:
Seneca County Office Building
1 DiPronio Drive
Waterloo, NY 13165
Steuben County:
3 Pulteney Square
Bath, NY 14810
Suffolk County:
Judith A. Pascale
Suffolk County Clerk
310 Center Drive
Riverhead, NY 11901-3392
Sullivan County:
Daniel Briggs
County Clerk
Sullivan County Government Center
100 North Street, P.O. Box 5012
Monticello, NY 12701-5012

Saint Lawrence County:
48 Court Street
Canton, NY 13617

Tioga County:
16 Court Street
P.O. Box 307
Owego, NY 13827

Saratoga County:
40 McMaster Street
Ballston Spa, NY 12020

Tompkins County:
320 N. Tioga Street
Ithaca, NY 14850

38

Ulster County:
Ulster County Clerk
Ulster County Office Building
244 Fair Street
Kingston, NY 12401
Warren County:
Warren County Municipal Center
1340 State Route 9
Lake George, NY 12845
Washington County:
Municipal Center
383 Broadway
Building A
Fort Edward, New York 12828
Wayne County:
9 Pearl Street
PO Box 608
Lyons, NY 14489
Westchester County:
110 Dr. Martin Luther King Jr. Blvd.
White Plains, NY 10601
Wyoming County:
143 North Main Street
Suite 104
Warsaw, NY 14569
Yates County:
417 Liberty Street, Suite 1107
Penn Yan, NY 14527

39

Appendix H: Filing Fee Waiver Paperwork

40

Supreme Court of the State of New York
County of _______
------------------------------------------------------------------------x
In the Matter of the Application of
|
|
PETITION FOR
|
__________________________
|
CHANGE OF NAME
|
|
for Leave to Assume the Name of
|
|
_________________________
|
|
------------------------------------------------------------------------x

AFFIDAVIT IN SUPPORT
OF APPLICATION
PURSUANT TO C.P.L.R.
1101(f) FOR REDUCED
FILING FEES
Index No. ________

YOUR NAME, being duly sworn, deposes and says:

1. I am the Petitioner in this proceeding.
2. I am a prisoner of the State of New York incarcerated at _____ Correctional Facility, in the
County of ______ and State of New York.
3. I am about to commence this proceeding to Petition for a change of name to better reflect my
gender identity under Article 6 of the New York State Civil Rights Laws
4. I make this affidavit in support of my application for a reduction of the filing fee pursuant to
C.P.L.R. § 1101(f).
5. I currently receive income from the following sources, exclusive of correctional facility wages:______________________________________________________
_________________________________________________________________.
6. My income from prison wages is approximately ________ per week. During the past six
months my income averaged approximately _______ per week. The court will be able to obtain the exact amounts of my prison earnings from my inmate account statement which I
have authorized below to be provided to the court from the Department of Corrections and
Community Supervision.
7. I own the following property, excluding miscellaneous personal property:
◻ NONE
◻ List Property:

Value:

41

______________________

____________________

______________________

____________________

______________________

____________________

______________________

____________________

8. I have no savings, property assets or income other than as set forth herein.
9. I am unable to pay the total filing fee necessary to prosecute this action.
10. No other person who is able to pay the filing fee has a beneficial interest in the result of this
proceeding.
11. I have made no prior request for relief in this case.
WHEREFORE, I request that I be permitted to prosecute this action as a poor person and be
permitted to file this claim with payment of a reduced filing fee.
_________________________________
YOUR NAME

Sworn to before me this ______ day
of ______________________, 2017
____________________________
Notary Public

42

(Please review this form carefully. You need only fill out the sections where it says “fill out” – the
sections that are left blank are for the Judge or Clerk to fill out at the right time.)
At a ______ Term, Part ____of the _______
Court of the State of New York, held in and
for the County of _____, New York on the ___
day of ______ , 2017

PRESENT: HON. _____________________
Supreme Court of the State of New York
County of _______
------------------------------------------------------------------------x
In the Matter of the Application of
|
|
PETITION FOR
|
__”fill out”___________________
|
CHANGE OF NAME
|
|
for Leave to Assume the Name of
|
|
__________”fill out”________________
|
|
------------------------------------------------------------------------x

ORDER ALLOWING
PROCEEDING AS A
POOR PERSON

Index No. ________

Upon the annexed Motion of YOUR NAME and Petition of YOUR NAME, verified on
the_______, And it being alleged that Petitioner has a good cause of action for Proceeding as a Poor
Person given Petitioner’s current financial situation including ________________. And it being alleged
that Petitioner is unable to pay the costs and fees to proceed in this action and that there is no other person beneficially interested in this action thereof.

Now on Motion of YOUR NAME Petitioner, it is hereby ORDERED that the motion is granted and the
Petitioner is permitted to proceed herein as a poor person and it is further ORDERED that the County
Clerk shall make no charge in connection with the fees associated with this matter and shall accept for
filing a Request for Judicial Intervention without payment of fees.

43

Dated:

Albany, New York

__________________, 2017

ENTER

___________________________
Judge, Civil Court

44

AUTHORIZATION

I, YOUR NAME, inmate number XX-X-XXXX, request and authorize the agency
holding me in custody to send to the Clerk of the Court certified copies of the correctional facility trust fund account statement (or the institutional equivalent) for the past six
months.
I further request and authorize the agency holding me in custody to calculate the
amounts specified by C.P.L.R. § 1101(f)(2), to deduct those amounts from my correctional facility trust fund account (or the institutional equivalent) and to distribute those
amounts as instructed by the Court.
This authorization is furnished in connection with the above-entitled case and shall
apply to any agency into whose custody I may be transferred.
I understand that the entire filing fee as determined by the court will be paid in installments by automatic deductions from my correctional facility trust fund account even
if my case is dismissed.

__________________________________
YOUR NAME,
DIN: XX-X-XXXX

Sworn to before me this ______ day
of __________________________, 2017
____________________________
Notary Public

45

Appendix I: Notice of Petition

46

The Office of the ___ County District Attorney
Street Address
City, State Zip
Date

RE:

In the Matter of the Application of _______ for Leave to Assume the Name of
__________, County of __________ Index No: _________

To Whom It May Concern:
Enclosed please find a copy of the Petition for Individual Adult Change of Name for the abovereferenced matter.
Pursuant to Civil Rights Law §62.2 notice of time and place when and where the petition will be
presented shall be served upon the district attorney and upon the courts in which the petitioner has been
convicted and sentenced for any felonies.
My petition for a name change has been scheduled for _________ in the _______ Supreme Court
before Honorable Judge _______.
Thank you for your time and consideration with this matter.

Sincerely,

Your Name
Enclosed:
Copy of Petition for Individual Adult Change of Name

47

Appendix J: Draft Affidavit of Serving

48

Supreme Court of the State of New York
County of _______
------------------------------------------------------------------------x
In the Matter of the Application of
|
|
PETITION FOR
|
__________________________
|
CHANGE OF NAME
|
|
for Leave to Assume the Name of
|
|
_________________________
|
|
------------------------------------------------------------------------x

AFFIDAVIT OF
SERVICE

Index No. ________

STATE OF NEW YORK
COUNTY OF NEW YORK
Service by Mail
NAME OF SERVER, affirms under penalties of perjury that:
1.

I am over eighteen years of age and not a party to this action.

2.

On DATE at approximately TIME, I placed a copy of the Petition for Individual Adult Change
of Name with a cover letter in an addressed envelope which I provided to the Correctional Facility I currently reside in where it was stamped and mailed out. The envelope was addressed to
_______________.

Dated: New York, N.Y.
DATE

_____________________
NAME OF SERVER

Sworn to before me this ______ day
of ______________________, 2017
____________________________
Notary Public

49

Appendix K: Legal Service Addresses

50

Legal Aid Society’s Prisoners Rights Project:
Legal Aid Society
Attn: Prisoner Rights Project
199 Water Street
New York, NY 10038
Tel: (212) 577-3300
Fax: (212) 509-8761
Peter Cicchino Youth Project:
Urban Justice Center
Attn: Peter Cicchino Youth Project
40 Rector Street, 9th Floor
New York, NY 10006
Prisoners’ Legal Services of New York
Prisoners’ Legal Services of New York has four separate offices across the state. To avoid any delay in
your case, be sure to read this list thoroughly and write to the appropriate office.
If you or your loved one are in: Bedford Hills, CNYPC, Coxsackie, Downstate, Eastern, Edgecombe,
Fishkill, Great Meadow, Greene, Greenhaven, Hale Creek, Hudson, Lincoln, Marcy, Midstate, Mohawk,
Otisville, Queensboro, Shawangunk, Sing Sing, Sullivan, Taconic, Ulster, Wallkill, Walsh, Washington,
Woodbourne then write to:
Prisoners’ Legal Services of New York
41 State Street, Suite M112
Albany, New York 12207
If you or your loved one are in: Albion, Attica, Collins, Gowanda, Groveland, Lakeview, Livingston,
Orleans, Rochester, Wende, Wyoming then write to:
Prisoners’ Legal Services of New York
14 Lafayette Square, Suite 510
Buffalo, New York 14203
If you or your loved one are in: Auburn, Cape Vincent, Cayuga, Elmira, Five Points, Monterey Shock,
Southport, Watertown, Willard then write to:
Prisoners’ Legal Services of New York
114 Prospect Street
Ithaca, New York 14850
If you or your loved one are in: Adirondack, Altona, Bare Hill, Clinton, Franklin, Gouverneur,
Riverview, Upstate then write to:
Prisoners’ Legal Services of New York
24 Margaret Street, Suite 9
Plattsburgh, New York 12901

51