Preview
FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024
New York State Unified Court System nycourts.gov
uCS-NC1
Name Change and/or Sex (o7/2023)
Page 1 of 4
Designation Change Petition
nvcourthelp.aov
for Individual Adult (perSon 18 or
over)
Court
County of buHO
e)-
Petitioner (Your res nt N Index Number:
I am requesting a Court Order for the following (check all that apply):
Name Change (complete Section A below)
O 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
designation 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 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.
SECTION A: NAME CHANGE (complete this section for a name change)
1. Your Requested New Name: CL ACA (U DCC
2. Your Place of Birth (Street Address, City/Town/Village, State, Zip, Country):
Note: You must attach Proof of birth to this petition.
" If you were bom 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 bom in the State of New York, you must attach one of the following:
o Certified Copy of your govemment-issued birth document (i.e., Birth Certificate/Certification of Birth):
" If you were born in New York City, you can get a certified of your birth document from the
copy
New York City Department of Health and Mental Hygiene
" If you were born outside New York City, you can get a certified of your birth document from
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 Spoken or Sign Language Interpreters , 3 1-800-COURT-NY
ggyp
ada@nycourts.aov interpreter@nycourts.gov (268-7869)
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FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024
UCS-NC1 (07/2023) Page 2 of 4 Index Number:
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 No
7. Are there anyJudgments or liens against you? O Yes No
8. Are you a party in a lawsuit or other court case? O Yes 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
Žes'
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 O No
'No,'
If how much do you owe? $
14.Court that issued the child support order:
15.Child Support Collections Unit:
16.Do you have to pay spousal support? O Yes No
Žes'
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
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.
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FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024
UCS-NC1 Page 3 of 4 Index Number:
(07/2023)
20.What are your reasons for changing your name? .
Provide details below.
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 Žes, 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: CLb Q
25.Your Age: ) (5
26.Your Date of Birth (Month/Day/Year):
27.Your Current Address (Street Address, City/Town/Village, State, Zip, Country):
NOTE: The court may require you to show roof of address when you file your petition.
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FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024
UCS-NCT 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 Yes No
Žes,'
If list the name or a description of the document(s) below.
30.1 respectfully request a Court Order permitting my name change and/or Osex
designati n change
Petitioner Signature Date
VERIFICATION
State of New York, County of OAway ss.:
I, fÒt 0 , the petitioner, being duly sworn,
have read the above petition and say that the information in t e petition is tr an accurate to the
best of my knowledge and belief.
Petitioner Signature in Presence of Notary
Sworn to before me this ll
day of v..ce-ry,eer , 20 -
s JESSICA SINGH
NOTARY PUBLIC, sTATE OF NEW YORK
C . Registration No. 01S16412294
Notary Pubhc
Qualified in Queens County
Commission Expires December 28, 2024
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
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Preview
FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024 New York State Unified Court System nycourts.gov uCS-NC1 Name Change and/or Sex (o7/2023) Page 1 of 4 Designation Change Petition nvcourthelp.aov for Individual Adult (perSon 18 or over) Court County of buHO e)- Petitioner (Your res nt N Index Number: I am requesting a Court Order for the following (check all that apply): Name Change (complete Section A below) O 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 designation 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 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. SECTION A: NAME CHANGE (complete this section for a name change) 1. Your Requested New Name: CL ACA (U DCC 2. Your Place of Birth (Street Address, City/Town/Village, State, Zip, Country): Note: You must attach Proof of birth to this petition. " If you were bom 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 bom in the State of New York, you must attach one of the following: o Certified Copy of your govemment-issued birth document (i.e., Birth Certificate/Certification of Birth): " If you were born in New York City, you can get a certified of your birth document from the copy New York City Department of Health and Mental Hygiene " If you were born outside New York City, you can get a certified of your birth document from 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 Spoken or Sign Language Interpreters , 3 1-800-COURT-NY ggyp ada@nycourts.aov interpreter@nycourts.gov (268-7869) 1 of 4 FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024 UCS-NC1 (07/2023) Page 2 of 4 Index Number: 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 No 7. Are there anyJudgments or liens against you? O Yes No 8. Are you a party in a lawsuit or other court case? O Yes 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 Žes' 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 O No 'No,' If how much do you owe? $ 14.Court that issued the child support order: 15.Child Support Collections Unit: 16.Do you have to pay spousal support? O Yes No Žes' 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 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. 2 of 4 FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024 UCS-NC1 Page 3 of 4 Index Number: (07/2023) 20.What are your reasons for changing your name? . Provide details below. 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 Žes, 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: CLb Q 25.Your Age: ) (5 26.Your Date of Birth (Month/Day/Year): 27.Your Current Address (Street Address, City/Town/Village, State, Zip, Country): NOTE: The court may require you to show roof of address when you file your petition. 3 of 4 FILED: SUFFOLK COUNTY CLERK 01/18/2024 04:05 PM INDEX NO. 601456/2024 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 01/18/2024 UCS-NCT 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 Yes No Žes,' If list the name or a description of the document(s) below. 30.1 respectfully request a Court Order permitting my name change and/or Osex designati n change Petitioner Signature Date VERIFICATION State of New York, County of OAway ss.: I, fÒt 0 , the petitioner, being duly sworn, have read the above petition and say that the information in t e petition is tr an accurate to the best of my knowledge and belief. Petitioner Signature in Presence of Notary Sworn to before me this ll day of v..ce-ry,eer , 20 - s JESSICA SINGH NOTARY PUBLIC, sTATE OF NEW YORK C . Registration No. 01S16412294 Notary Pubhc Qualified in Queens County Commission Expires December 28, 2024 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