Preview
BUR L 000617-19 03/18/2019 Pg 1 of5 Trans ID: ECV 2019524623
?
Form A
Dustin Thomas Knox Superior Court of New Jersey
‘Name Law Division
550 Kettle Run Road Burlington
‘Street Address
County 201 12 AMI Ty
Marlton, NJ 08053 Docket No.wb
a B
City, State, Zip bE
Telephone Number
In the Matter of the Application of: Civil Action
Dustin Thomas Knox
Your Name Verified Complaint Including
Certification of Plaintiff for Name
To Assume the Name of:
Change
Dustin Thomas Sanchez
Name you wish to assume
The plaintiff, Dustin Thomas Knox whose place of residence is
(your name, first, middle, last)
550 Kettle Run Road in the City of Marlton , County of
idress) (City)
Burlington fh in the State of New Jersey says:
(County
lam the Plaintiff in this matter.
My current legal name is Dustin Thomas Knox
(your name, first, middle, last)
My social security number can be found in the attached Certification of Confidential Information for
Name Change.
I was born on 10/17/2000 in __ Philadelphia, Pennsylvania .
(month, day, year) (place of birth)
Ihave since birth been identified by the following names: (first, middle, last)
Dustin Thomas Knox
I (check one) []have [J have not been married.
I (check one) [have [have never been convicted of a crime, and have no criminal charges
pending against me, except: (please supply county, municipality, nature, date of crime and/or pending charges)
This application (check one) [is {is not being made with the intent to avoid creditors or criminal
prosecution or for other fraudulent purpose.
BUR L 000617-19 03/18/2019 Pg 2 of 5 Trans ID: LCV2019524623
FormA
9. I(checkone) (Jhave [have no unsatisfied judgments of record, or suits pending against me,
except: (enter any recorded judgments or pending suits)
10. I request this name change for the following reasons:
No longer wish to carry the surname of my father
11. I (heck one) [have Ml have not made any previous applications to assume another name.
12. I (check one) [Jdo ff do not have any pending applications for a name change in any other court or
jurisdiction to the best of my knowledge and belief, except: (enter the state, county and docket number(s) of
any pending applications)
13. l understand that I must advise the court if there are any changes in the facts stated in this Verified
Complaint.
WHEREFORE, plaintiff demands judgmentPibhie-
to N.I.S.A, 9 :52-1 to -4. ete
Pash of Plaintiff
Certification
I certify that the foregoing statements made by me are true. | am aware that if any of the foregoing
statements made by me are willfully false, I am subj ject to Siew The Io
tig Signature of Plaintiff
BUR L 000617-19 03/18/2019 Pg 3 of5 Trans ID: LCV2019524623
Form B
Dustin Thomas Knox Superior Court of New Jersey
Name Law Division
550 Kettle Run Road Burlington {<4 County
Street Address
Marlton, NJ 08053 Docket No.
City, State, Zip (To be filled in by the court)
609-332-4322
Telephone Number
In the Matter of the Application of:
Dustin Thomas Knox Civil Action
Your Name
Order Fixing Date of Hearing
To Assume the Name of:
Dustin Thomas Sanchez
Name you wish to assume
Application being made to the Court by Dustin Thomas Knox >
(your name, first, middle, last)
for a judgment authorizing (check one) [him []her to assume another name and for the entry of an
order fixing a date for the hearing of such application,
DO NOT WRITE BELOW THIS LINE THE COURT WILL COMPLETE
IT IS ON THIS day of ,20__, ORDERED that the day of
»20__, at a.m., or as soon thereafter as the matter can be heard, at the courthouse
in the City of County of , State of New Jersey, be fixed as the
time and place for the hearing of such application and of any objections that may be made thereto.
IT IS FURTHER ORDERED that a notice of such application be published in
once, at least two (2) weeks preceding the
date set for the hearing.
IS.C
NOTE: A copy of the Order Fixing Date of Hearing must be sent via regular mail and certified mail to
the newspaper for publication and served on the Director of the Division of Criminal Justice. If there
are criminal charges pending, copies of the Verified Complaint, Certification of Confidential
for Name Change and Order Fixing Date of Hearing must be sent via regular mail and
Information
ertified mail and served on the County Prosecutor and/or the Office of the Attorney General.
BUR L 000617-19 03/18/2019 Pg 4 of5 Trans ID: LCV2019524623
Form C
Dustin Thomas Knox Superior Court Of New Jersey
Name Law Division
550 Kettle Run Road Burlington b~| County
Street Address
Marlton, NJ 08053 Docket No.
City, State, Zip (To be filled in by the court)
609- ~4322.
Telephone Number
In the Matter of the Application of:
Dustin Thomas Knox Civil Action
Your Name
Final Judgment
To Assume the Name of:
Dustin Thomas Sanchez
Name you wish to assume
Dustin Thomas Knox having made application to this Court by duly
(your name, first, middle, last)
verified complaint for a judgment authorizing (check one) [him (her to assume the name of
Dustin Thomas Sanchez and it appearing to the Court that all the provisions of
(name you wish to assume)
N.J.S.A, 2A:52-1-4 and the Current N.J. Court Rules relating thereto have been complied with:
ITIS ON THIS ____ day of , 20__, ORDERED and ADJUDGED that
(leave blank for the court to complete)
Dustin Thomas Knox. who was born on 10/17/2000 , and whose social
(your name, first, middle, last) (month, day, year)
security number is contained in the attached Final Judgment Addendum, be and hereby is authorized to
assume the name of Dustin Thomas Sanchez , effective
(name you wish to assume) (eave blank for the court to complete)
(NOTE: This is the date you may begin using your assumed name), and
DO NOT WRITE BELOW THIS LINE THE COURT WILL COMPLETE
IT IS FURTHER ORDERED that within twenty days hereof, plaintiff shall cause a copy of only the
Final Judgment (not the Final Judgment Addendum) to be published once in
and within forty-five days after entry of Judgment, plaintiff shall file proof of
publication of this Final Judgment with the deputy clerk of the Superior Court (in the county in which you filed
your Verified Complaint);
IT IS FURTHER ORDERED that the published version of the Final Judgment shall not contain the
social security number of the person whose name was changed; and
IT IS FURTHER ORDERED that within forty-five days after entry of Judgment, a certified copy of
this Final Judgment, with the Final Judgment Addendum attached, must be sent to the Department of Treasury
mursuant to the nravisions of the Statnte and Rules in ench eace mada and nravided
BUR L 000617-19 03/18/2019 Pg 5 of 5 Trans ID: LCV2019524623
Appendix XII-B1
CiviL CASE INFORMATION STATEMENT
sx (CIS) Cue/ck No.
YSy,
fon Use for initial Law Division AMOUNT:
‘ooo
ooo Civil Part pleadings (not motions) under Rule 4:5-1
Pleading will be rejected for filing, under Rule 1:5-6(c), OVERPAYMENT:
if information above the black bar is not completed
or attorney's signature is not affixed BATCH NUMBER:
ATTORNEY/ PRO SE NAME TELEPHONE NUMBER COUNTY OF VENUE
Dustin Thomas Knox (856) 979-7031 Burlington Hy
FIRM NAME (if applicable) DOCKET NUMBER (when available)
OFFICE ADDRESS. DOCUMENT TYPE
550 Kettle Run Road
Marlton, NJ 08053
JURY DEMAND D Yes Hino
NAME OF PARTY (e.g., John Doe, Plaintiff) CAPTION
Dustin Thomas Knox, Plaintiff
CASE TYPE NUMBER HURRICANE SANDY
(See reverse side for listing) RELATED? IS THISA PROFESSIONAL MALPRACTICE CASE? O Yes MNO
151
Yes No IF YOU HAVE CHECKED “YES,” SEE N.J.S.A. 2A:53 A -27 AND APPLICABLE CASE LAW
REGARDING YOUR OBLIGATION TO FILE AN AFFIDAVIT OF MERIT.
RELATED CASES PENDING? IF YES, LIST DOCKET NUMBERS
O Yes HI No
DO YOU ANTICIPATE ADDING ANY PARTIES NAME OF DEFENDANT'S PRIMARY INSURANCE COMPANY (if known)
(arising out of same transaction or occurrence)? D None
Q Yes No 0 UNKNown
mea eee) Basted fo Ralse Ce] er LOM =]-8) Ns ce]8]u1e1
12k Ek en AU
CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATION
DO PARTIES HAVE A CURRENT, PAST OR IF YES, IS THAT RELATIONSHIP:
RECURRENT RELATIONSHIP? (1 EMPLOYER/EMPLOYEE, O FRIEND/NEIGHEOR C1 OTHER (explain)
Q Yes 0 No O Fama O Business
DOES THE STATUTE GOVERNING THIS CASE PROVIDE FOR PAYMENT OF FEES BY THE LOSING PARTY? O Yes 1 No
USE THIS SPACE TO ALERT THE COURT TO ANY SPECIAL CASE CHARACTERISTICS THAT MAY WARRANT INDIVIDUAL MANAGEMENT OR
ACCELERATED DISPOSITION
Do You OR YOUR CLIENT NEED ANY DISABILITY ACCOMMODATIONS? IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION
| O Yes No
WILL AN INTERPRETER BE NEEDED? IF YES, FOR WHAT LANGUAGE?
C Yes No
| certify that confidential personal identifiers have been redacted from documents now submitted to the court, and will be
redacted from ail documents submitted in the future in accordance with Rule 1:38-7(b).
ATTORNEY SIGNATURE: Pusae Thera fr Ol
Effective 10/10/2018, CN 10517_ps
page 4 of 5
Preview
BUR L 000617-19 03/18/2019 Pg 1 of5 Trans ID: ECV 2019524623 ? Form A Dustin Thomas Knox Superior Court of New Jersey ‘Name Law Division 550 Kettle Run Road Burlington ‘Street Address County 201 12 AMI Ty Marlton, NJ 08053 Docket No.wb a B City, State, Zip bE Telephone Number In the Matter of the Application of: Civil Action Dustin Thomas Knox Your Name Verified Complaint Including Certification of Plaintiff for Name To Assume the Name of: Change Dustin Thomas Sanchez Name you wish to assume The plaintiff, Dustin Thomas Knox whose place of residence is (your name, first, middle, last) 550 Kettle Run Road in the City of Marlton , County of idress) (City) Burlington fh in the State of New Jersey says: (County lam the Plaintiff in this matter. My current legal name is Dustin Thomas Knox (your name, first, middle, last) My social security number can be found in the attached Certification of Confidential Information for Name Change. I was born on 10/17/2000 in __ Philadelphia, Pennsylvania . (month, day, year) (place of birth) Ihave since birth been identified by the following names: (first, middle, last) Dustin Thomas Knox I (check one) []have [J have not been married. I (check one) [have [have never been convicted of a crime, and have no criminal charges pending against me, except: (please supply county, municipality, nature, date of crime and/or pending charges) This application (check one) [is {is not being made with the intent to avoid creditors or criminal prosecution or for other fraudulent purpose. BUR L 000617-19 03/18/2019 Pg 2 of 5 Trans ID: LCV2019524623 FormA 9. I(checkone) (Jhave [have no unsatisfied judgments of record, or suits pending against me, except: (enter any recorded judgments or pending suits) 10. I request this name change for the following reasons: No longer wish to carry the surname of my father 11. I (heck one) [have Ml have not made any previous applications to assume another name. 12. I (check one) [Jdo ff do not have any pending applications for a name change in any other court or jurisdiction to the best of my knowledge and belief, except: (enter the state, county and docket number(s) of any pending applications) 13. l understand that I must advise the court if there are any changes in the facts stated in this Verified Complaint. WHEREFORE, plaintiff demands judgmentPibhie- to N.I.S.A, 9 :52-1 to -4. ete Pash of Plaintiff Certification I certify that the foregoing statements made by me are true. | am aware that if any of the foregoing statements made by me are willfully false, I am subj ject to Siew The Io tig Signature of Plaintiff BUR L 000617-19 03/18/2019 Pg 3 of5 Trans ID: LCV2019524623 Form B Dustin Thomas Knox Superior Court of New Jersey Name Law Division 550 Kettle Run Road Burlington {<4 County Street Address Marlton, NJ 08053 Docket No. City, State, Zip (To be filled in by the court) 609-332-4322 Telephone Number In the Matter of the Application of: Dustin Thomas Knox Civil Action Your Name Order Fixing Date of Hearing To Assume the Name of: Dustin Thomas Sanchez Name you wish to assume Application being made to the Court by Dustin Thomas Knox > (your name, first, middle, last) for a judgment authorizing (check one) [him []her to assume another name and for the entry of an order fixing a date for the hearing of such application, DO NOT WRITE BELOW THIS LINE THE COURT WILL COMPLETE IT IS ON THIS day of ,20__, ORDERED that the day of »20__, at a.m., or as soon thereafter as the matter can be heard, at the courthouse in the City of County of , State of New Jersey, be fixed as the time and place for the hearing of such application and of any objections that may be made thereto. IT IS FURTHER ORDERED that a notice of such application be published in once, at least two (2) weeks preceding the date set for the hearing. IS.C NOTE: A copy of the Order Fixing Date of Hearing must be sent via regular mail and certified mail to the newspaper for publication and served on the Director of the Division of Criminal Justice. If there are criminal charges pending, copies of the Verified Complaint, Certification of Confidential for Name Change and Order Fixing Date of Hearing must be sent via regular mail and Information ertified mail and served on the County Prosecutor and/or the Office of the Attorney General. BUR L 000617-19 03/18/2019 Pg 4 of5 Trans ID: LCV2019524623 Form C Dustin Thomas Knox Superior Court Of New Jersey Name Law Division 550 Kettle Run Road Burlington b~| County Street Address Marlton, NJ 08053 Docket No. City, State, Zip (To be filled in by the court) 609- ~4322. Telephone Number In the Matter of the Application of: Dustin Thomas Knox Civil Action Your Name Final Judgment To Assume the Name of: Dustin Thomas Sanchez Name you wish to assume Dustin Thomas Knox having made application to this Court by duly (your name, first, middle, last) verified complaint for a judgment authorizing (check one) [him (her to assume the name of Dustin Thomas Sanchez and it appearing to the Court that all the provisions of (name you wish to assume) N.J.S.A, 2A:52-1-4 and the Current N.J. Court Rules relating thereto have been complied with: ITIS ON THIS ____ day of , 20__, ORDERED and ADJUDGED that (leave blank for the court to complete) Dustin Thomas Knox. who was born on 10/17/2000 , and whose social (your name, first, middle, last) (month, day, year) security number is contained in the attached Final Judgment Addendum, be and hereby is authorized to assume the name of Dustin Thomas Sanchez , effective (name you wish to assume) (eave blank for the court to complete) (NOTE: This is the date you may begin using your assumed name), and DO NOT WRITE BELOW THIS LINE THE COURT WILL COMPLETE IT IS FURTHER ORDERED that within twenty days hereof, plaintiff shall cause a copy of only the Final Judgment (not the Final Judgment Addendum) to be published once in and within forty-five days after entry of Judgment, plaintiff shall file proof of publication of this Final Judgment with the deputy clerk of the Superior Court (in the county in which you filed your Verified Complaint); IT IS FURTHER ORDERED that the published version of the Final Judgment shall not contain the social security number of the person whose name was changed; and IT IS FURTHER ORDERED that within forty-five days after entry of Judgment, a certified copy of this Final Judgment, with the Final Judgment Addendum attached, must be sent to the Department of Treasury mursuant to the nravisions of the Statnte and Rules in ench eace mada and nravided BUR L 000617-19 03/18/2019 Pg 5 of 5 Trans ID: LCV2019524623 Appendix XII-B1 CiviL CASE INFORMATION STATEMENT sx (CIS) Cue/ck No. YSy, fon Use for initial Law Division AMOUNT: ‘ooo ooo Civil Part pleadings (not motions) under Rule 4:5-1 Pleading will be rejected for filing, under Rule 1:5-6(c), OVERPAYMENT: if information above the black bar is not completed or attorney's signature is not affixed BATCH NUMBER: ATTORNEY/ PRO SE NAME TELEPHONE NUMBER COUNTY OF VENUE Dustin Thomas Knox (856) 979-7031 Burlington Hy FIRM NAME (if applicable) DOCKET NUMBER (when available) OFFICE ADDRESS. DOCUMENT TYPE 550 Kettle Run Road Marlton, NJ 08053 JURY DEMAND D Yes Hino NAME OF PARTY (e.g., John Doe, Plaintiff) CAPTION Dustin Thomas Knox, Plaintiff CASE TYPE NUMBER HURRICANE SANDY (See reverse side for listing) RELATED? IS THISA PROFESSIONAL MALPRACTICE CASE? O Yes MNO 151 Yes No IF YOU HAVE CHECKED “YES,” SEE N.J.S.A. 2A:53 A -27 AND APPLICABLE CASE LAW REGARDING YOUR OBLIGATION TO FILE AN AFFIDAVIT OF MERIT. RELATED CASES PENDING? IF YES, LIST DOCKET NUMBERS O Yes HI No DO YOU ANTICIPATE ADDING ANY PARTIES NAME OF DEFENDANT'S PRIMARY INSURANCE COMPANY (if known) (arising out of same transaction or occurrence)? D None Q Yes No 0 UNKNown mea eee) Basted fo Ralse Ce] er LOM =]-8) Ns ce]8]u1e1 12k Ek en AU CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATION DO PARTIES HAVE A CURRENT, PAST OR IF YES, IS THAT RELATIONSHIP: RECURRENT RELATIONSHIP? (1 EMPLOYER/EMPLOYEE, O FRIEND/NEIGHEOR C1 OTHER (explain) Q Yes 0 No O Fama O Business DOES THE STATUTE GOVERNING THIS CASE PROVIDE FOR PAYMENT OF FEES BY THE LOSING PARTY? O Yes 1 No USE THIS SPACE TO ALERT THE COURT TO ANY SPECIAL CASE CHARACTERISTICS THAT MAY WARRANT INDIVIDUAL MANAGEMENT OR ACCELERATED DISPOSITION Do You OR YOUR CLIENT NEED ANY DISABILITY ACCOMMODATIONS? IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION | O Yes No WILL AN INTERPRETER BE NEEDED? IF YES, FOR WHAT LANGUAGE? C Yes No | certify that confidential personal identifiers have been redacted from documents now submitted to the court, and will be redacted from ail documents submitted in the future in accordance with Rule 1:38-7(b). ATTORNEY SIGNATURE: Pusae Thera fr Ol Effective 10/10/2018, CN 10517_ps page 4 of 5