Preview
FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024
New York State Unified Court System nycourts.gov
VCS-NC1
Name Change and/or Sex (07/2023)
. Page 1 of 4
Designation Change Petition
'
nvcourthelp.qov
for Individual Adult (perSon 18 or over)
Court
ounty of
Petitioner (Your Present Name): Index Number:
I am requesting a Court Order for the following (check all that apply):
ÓName Change (complete Section A below)
¡ Sex Designation Change (complete Section B below)
Please note:
" A court order is not required under New York law to change your sex designation on an identity
document (birth certificate, driver's license, photo ID, etc.) issued in New York.
" state has its own requirements for a sex designation change. Some states not honor sex
Every may
designatiori change orders from New York courts. If you want to change an identity document
issued in another state, you should check that state's requirements before you file an application.
" This application is for a declaratory judgment. A declaratory judgment states a fact under the law. If
granted, the sex designation change order legally recognizes your gender identity. .
Are you asking the judge to seal the record for your personal safety? O Yes 4 No
"Restricted"
NOTE: If yes, the clerk will temporarily enter your case as (your name and case
information will be private) until the judge makes a final decision about sealing your case. .
1. Your Requested New Name: ch ()t.)( )O ( LD .,
2. Your Place of Birth (Street Address, City/Town/Village, S ate, Zip, Country):
ovcekfk(,kk
Note: You must attach Proof of birth t this petition.
" If you were born outside of the State of New York, proof of birth can include a birth certificate, passport,
or any other legal document which shows the date and place of your birth.
* If you were born in the State of New York, you must attach one of the following:
o Certified Copy of your government-issued birth document (i.e., Birth Certificate/Certification of Birth):
* If you were born in New York you can get a certified of your birth document from the
City, copy
New York City Department of Health and Mental Hygiene
" If you were born outside New York you can get a certified of your birth document from
City, copy
the New York State Department.of Health's Vital Records Department
o Certified Transcript of your Birth Certificate
o Certificate from Commissioner or local Board of Health stating no such Certificate is available
*
ADA Accommodations a é spoken or sign tanguage nterprotors
cous
¹-800-COURT-NY
L ada@nycourts.qov interpreter@nycourts.gov (268-7869)
1 of 4
FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024
UCS-NC1 Page 2 of 4 Index Number:
(07/20'23)
3. Have you ever been convicted of a crime? O Yes @ No
Žes'
If you answered to question 3, you must answer questions 4 and 5.
4. Court where you were convicted:
5. Crime for which you were convicted:
6. Have you ever filed for bankruptcy? O Yes O No
7. Are there any judgments or liens against you? O Yes 6 No
8. Are you a party in a lawsuit or other court case? Q Yes 6 No
Žes'
If you answered to question 6, 7 or 8, provide details below, including the court where it was
filed, the date it was filed, and the case number (if known).
9. Are you currently married? O Yes @ No
10.Were you previously married? O Yes No
11.Do you have any children under 21? O Yes @ No
12.Do you have to pay child support? O Yes @ No
'Yes'
If you answered to question 12, you must answer questions 13, 14 and 15.
13.Are your child support payments up to date? O Yes È No
'No,'
If how much do you owe? $
14.Court that issued the child suppo.rt order:
15.Child Support Collections Unit:
16.Do you have to pay spousal support? O Yes @ No
'Yes'
If you answered to question 16, you must answer questions 17 and 18.
17.Are your spousal support payments up to date? O Yes O No.
'No,'
If how much do you owe? $
18.Court that issued the spousal support order:
19.Have you ever filed a name change petition before? O Yes @ No
'Yes,'
If provide details below, including the court where you filed the petition, the date that you
filed it, the case number (if known), and the result.
2 of 4
FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024
UCS-NC1 Page 3 of 4 Index Number:
(07/2023)
20.What are your reasons for changing your name?
Provide details below. .
EEEGEEEE9EEEEEEEEBPEEEEEEEBFIERI
21.Your new sex designation: .
22.Have you ever filed a sex designation change petition before? O Yes O No
Žes,'
If provide details below, including the court where you filed the petition, the date that you
filed it, the case number (if known), and the result.
23.Do you want to provide your reasons for changing your sex designation? O Yes O No
'No,'
If Yes/ you may provide details below. If leave this question blank. Please.note, this
information is optional and is not required for a court order to change your sex designation.
24.Your Present Name.: 4
25.Your Age:
26.Your Date of Birth (Month/Day/Year): ()LÎ I) 0
27.Your Current Address (Street Address, City/Town/Village, State, Zip, Country):
NOTE: The court may require you to show proof of address when you file your petition.
3 of 4
FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024
UCS-NC1 Page 4 of 4 Index Number:
(07/2023)
28.Should this court record be sealed for your personal safety? O Yes @ No
Žes,'
If provide details below.
29.Have you attached any supporting documents or additional pages? O Ves O No
Žes,'
If list the name or a description of the document(s) below.
30.I respectfully request a Court Órder permitting my ¡name change and/or Osex
designation change. .
Petiti e Date
VERIFICATION
State of New York, County of ss.:
/lth
I, , the petitioner, being duly sworn,
have read the above petition and say that the information in the petition is true and accurate to the
best of my knowledge and belief
"
Petitioner Sig a re Presence of Notary
Sworn to b e me this
day of , .
JUUO ROMOLEROUX
6'Î!o°s',New York
Notary Public
Qualified in Suffolk County
My Commission Expires Aug 4, 202A
Note: You can complete and submit a Fee Waiver Application form asking the court to waive the filing
fees for your application if you qualify. A fillable Fee Waiver Application form is available at:
https://www.nycourts.qov/CourtHelp/GoinqToCourt/feeWaiver-shtml
4 of 4
Preview
FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024 New York State Unified Court System nycourts.gov VCS-NC1 Name Change and/or Sex (07/2023) . Page 1 of 4 Designation Change Petition ' nvcourthelp.qov for Individual Adult (perSon 18 or over) Court ounty of Petitioner (Your Present Name): Index Number: I am requesting a Court Order for the following (check all that apply): ÓName Change (complete Section A below) ¡ Sex Designation Change (complete Section B below) Please note: " A court order is not required under New York law to change your sex designation on an identity document (birth certificate, driver's license, photo ID, etc.) issued in New York. " state has its own requirements for a sex designation change. Some states not honor sex Every may designatiori change orders from New York courts. If you want to change an identity document issued in another state, you should check that state's requirements before you file an application. " This application is for a declaratory judgment. A declaratory judgment states a fact under the law. If granted, the sex designation change order legally recognizes your gender identity. . Are you asking the judge to seal the record for your personal safety? O Yes 4 No "Restricted" NOTE: If yes, the clerk will temporarily enter your case as (your name and case information will be private) until the judge makes a final decision about sealing your case. . 1. Your Requested New Name: ch ()t.)( )O ( LD ., 2. Your Place of Birth (Street Address, City/Town/Village, S ate, Zip, Country): ovcekfk(,kk Note: You must attach Proof of birth t this petition. " If you were born outside of the State of New York, proof of birth can include a birth certificate, passport, or any other legal document which shows the date and place of your birth. * If you were born in the State of New York, you must attach one of the following: o Certified Copy of your government-issued birth document (i.e., Birth Certificate/Certification of Birth): * If you were born in New York you can get a certified of your birth document from the City, copy New York City Department of Health and Mental Hygiene " If you were born outside New York you can get a certified of your birth document from City, copy the New York State Department.of Health's Vital Records Department o Certified Transcript of your Birth Certificate o Certificate from Commissioner or local Board of Health stating no such Certificate is available * ADA Accommodations a é spoken or sign tanguage nterprotors cous ¹-800-COURT-NY L ada@nycourts.qov interpreter@nycourts.gov (268-7869) 1 of 4 FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024 UCS-NC1 Page 2 of 4 Index Number: (07/20'23) 3. Have you ever been convicted of a crime? O Yes @ No Žes' If you answered to question 3, you must answer questions 4 and 5. 4. Court where you were convicted: 5. Crime for which you were convicted: 6. Have you ever filed for bankruptcy? O Yes O No 7. Are there any judgments or liens against you? O Yes 6 No 8. Are you a party in a lawsuit or other court case? Q Yes 6 No Žes' If you answered to question 6, 7 or 8, provide details below, including the court where it was filed, the date it was filed, and the case number (if known). 9. Are you currently married? O Yes @ No 10.Were you previously married? O Yes No 11.Do you have any children under 21? O Yes @ No 12.Do you have to pay child support? O Yes @ No 'Yes' If you answered to question 12, you must answer questions 13, 14 and 15. 13.Are your child support payments up to date? O Yes È No 'No,' If how much do you owe? $ 14.Court that issued the child suppo.rt order: 15.Child Support Collections Unit: 16.Do you have to pay spousal support? O Yes @ No 'Yes' If you answered to question 16, you must answer questions 17 and 18. 17.Are your spousal support payments up to date? O Yes O No. 'No,' If how much do you owe? $ 18.Court that issued the spousal support order: 19.Have you ever filed a name change petition before? O Yes @ No 'Yes,' If provide details below, including the court where you filed the petition, the date that you filed it, the case number (if known), and the result. 2 of 4 FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024 UCS-NC1 Page 3 of 4 Index Number: (07/2023) 20.What are your reasons for changing your name? Provide details below. . EEEGEEEE9EEEEEEEEBPEEEEEEEBFIERI 21.Your new sex designation: . 22.Have you ever filed a sex designation change petition before? O Yes O No Žes,' If provide details below, including the court where you filed the petition, the date that you filed it, the case number (if known), and the result. 23.Do you want to provide your reasons for changing your sex designation? O Yes O No 'No,' If Yes/ you may provide details below. If leave this question blank. Please.note, this information is optional and is not required for a court order to change your sex designation. 24.Your Present Name.: 4 25.Your Age: 26.Your Date of Birth (Month/Day/Year): ()LÎ I) 0 27.Your Current Address (Street Address, City/Town/Village, State, Zip, Country): NOTE: The court may require you to show proof of address when you file your petition. 3 of 4 FILED: SUFFOLK COUNTY CLERK 05/06/2024 10:04 AM INDEX NO. 611200/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 05/06/2024 UCS-NC1 Page 4 of 4 Index Number: (07/2023) 28.Should this court record be sealed for your personal safety? O Yes @ No Žes,' If provide details below. 29.Have you attached any supporting documents or additional pages? O Ves O No Žes,' If list the name or a description of the document(s) below. 30.I respectfully request a Court Órder permitting my ¡name change and/or Osex designation change. . Petiti e Date VERIFICATION State of New York, County of ss.: /lth I, , the petitioner, being duly sworn, have read the above petition and say that the information in the petition is true and accurate to the best of my knowledge and belief " Petitioner Sig a re Presence of Notary Sworn to b e me this day of , . JUUO ROMOLEROUX 6'Î!o°s',New York Notary Public Qualified in Suffolk County My Commission Expires Aug 4, 202A Note: You can complete and submit a Fee Waiver Application form asking the court to waive the filing fees for your application if you qualify. A fillable Fee Waiver Application form is available at: https://www.nycourts.qov/CourtHelp/GoinqToCourt/feeWaiver-shtml 4 of 4