Connecticut Affidavit Re Change of Name (Adult) Form

RESET
Affidavit Re Change of Name (Adult)
PC-910 REV. 1/14
CONNECTICUT PROBATE COURTS
RECORDED:
RECEIVED:
Instructions:
1) Submit with form PC-901, Petition for Change of Name (Adult).
2) Type or print the form in ink.
Probate Court Name
District Number
In Re Change of Name of
The subscriber, being duly sworn, hereby swears, affirms or avers that:
1. I have petitioned this court for a change of name.
2. I presently live at: _____________________________________________________________________ and
have been a resident of _________________________________Connecticut for ______ years.
3. I own real estate located in ________________________________________.
4. I do not have any outstanding debts that are in arrears. I will notify my creditors of the change of name.
5.
A. There are no criminal charges pending against me.
B. There are criminal charges pending against me as described below:
C. I have never been convicted of any offense.
D. I have been convicted of a criminal offense(s) as described below:
Due to the nature of my offense, I am obligated to register on the Sex Offender Registry, and, prior to
filing this petition with the court, I notified the commissioner of emergency services and public protection
in accordance with C.G.S. section 45a-99.
Due to the nature of my offense, I am obligated to register on the Deadly Weapons Offender
Registry, and, prior to filing this petition with the court, I notified the commissioner of emergency services
and public protection in accordance with C.G.S. section 45a-99.
6. The purpose of the change of name is not to deceive, defraud or mislead any person or governmental agency,
nor to avoid the legal consequences of a criminal conviction.
7. I
have
have not previously petitioned for a change of name in either a Probate Court or the Superior
Court in Connecticut or in a court of another state.
Court name and address:
Subscriber__________________________________
Date:__________________
DATE
SUBSCRIBED AND SWORN TO
BEFORE ME
Judge, Clerk, Notary Public, Comm. of Superior Court
Affidavit Re Change of Name (Adult)
PC-910 REV. 1/14