Motion-Secondary: In the Matter of the Application of King Krompicha & Collin Chindavong for leave to change the name of Adalina Tidaphon Chindavong to assume the name Adalina Tidaphon Krompicha

• 
• 
• 
• 

						
                                
Preview
                                New York State Unified Court System                                                     nycourts.gov
         Tay
               a                                                                                 UCS-NCO1        (07/2023)
                      Order Granting Name Change
                                                                                                               Page 1 of 2
                      and/or Sex Designation Change
                                                                                                            ycourthelp.gov
                      for Individual Adult (person 18 or over)
Supreme                       Court
County of QUEENS

Present: Hon.
In the Matter of the Application of:                                               Index Number:
Adalina Tidaphon Chindavong



Upon the Petitioner’s application verified on                                  fora           Name Change
LC Sex Designation Change, and the Court being satisfied that said petition is true and that there is
no reasonable objection to the change(s) proposed; it is hereby,


 SECTION A: NAME             CHANGE        (complete this section for a name change)

    ORDERED          that Petitioner,   having   been born on       06/07/2007           in
    Methodist Hospital Saint Louis Park, Hennipen, Minnesota     and having     provided the following proof of birth:

        ©      Certified copy of birth certificate number             2007-MN-030685              issued by:
               State of Minnesota

        ©      Certified transcript of birth certificate number                                        issued by:


        O Certificate from                                                                      stating that no birth
               certificate is available,
        © Other:                                                                                                           ,
    is authorized to assume the name of                   Adalina Tidaphon   Krompicha            in place of Petitioner's
    present name,               Adalina Tidaphon Chindavong          , and Petitioner shall be known         by no other
    name;      and it is further,

OPTIONAL PROVISIONS (check all that apply):
    CJ ORDERED           that Petitioner shall serve a certified copy of this order upon the following parties
        based upon the following reasoning and good cause:




    (CO ORDERED          that Petitioner shall serve a certified copy of this order upon the following city, state
        or federal agencies based upon the following reasoning and good cause:




                                    Seley
    ° |ADA Accommodations                        Spoken or Sign Language Interpreters                         -800-COURT-NY
                                                                                                     Help           (268-7869)
Q     lada@nycourts.go’                          interpreter: nycourts.go'
UCS-NCO1         (07/2023)                                Page 2 of 2               Index Number:

   (C0 ORDERED           that, Petitioner having   been convicted of an offense listed in Civil Rights Law
         section 64(2)(a), the court clerk shall deliver a certified copy of this order by first-class mail to
         the Division of Criminal Justice Services; and it is further,

   CJ ORDERED            that Petitioner, being responsible for child support obligations pursuant to a court
         order, shall deliver certified copies of this order by first-class mail to the following court that
         issued the child support order:                                                  and to the Child
         Support Collection Unit:                                                       ; and it is further,

   (CJ ORDERED           that Petitioner, being responsible for spousal support obligations pursuant to a
         court order, shall deliver a certified copy of this order by first-class mail to the following court
         that issued the spousal support order:                                                                  ;and   itis
         further,


 SECTION       B: SEX DESIGNATION            CHANGE        (complete this section for a sex designation change)
 Please note:
   e     Acourt 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.
   e     Every state has its own requirements for a sex designation change.          If you want to change an identity
         document issued in another state, you should check that state’s requirements.
   e     This is a declaratory judgment.    A declaratory judgment states a fact under the law.       This sex
         designation change order legally recognizes your gender identity.

(0 ORDERED           that Petitioner, having attested to their gender identity or to the reason for the sex
   designation change, is authorized to assume the proposed sex designation of                                   and    itis
   further,


 SECTION       C: GENERAL         PROVISIONS       (complete this section for all orders)

ORDERED        that, upon     receipt of this order from the court, the Clerk of the Court shall         enter the order
and shall file the papers upon which it was granted; and it is further,

OPTIONAL PROVISION               (check if applicable):
   [J ORDERED              Oat Petitioner's request          ©sua       sponte that all paper and electronic records
         of this court proceeding are sealed and may be opened only by court order for good cause
         shown      or at Petitioner’s request; and it is further,

ORDERED that the authorizations contained herein are contingent upon Petitioner's full compliance
with the provisions and directives of this order.


Dated:
                                                                                   Judge Signature