Sylvia Rivera Law Project - Name Changes for Transgender Adults in New York State Prisons, 2017
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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 10 10 11 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 2 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 3 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 4 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 5 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 7 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. 8 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. 10 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. 11 Appendix A: Article 6: Civil Rights: Change of Name 12 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 firstname.lastname@example.org. 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