Affidavit Re Change Of Name (Adult) {PC-910}

Affidavit Re Change of Name (Adult) PC-910 REV. 1/14 RECEIVED: CONNECTICUT PROBATE COURTS RECORDED: Instructions: 1) Submit with form PC-901, Petition for Change of Name (Adult). 2) Type or print the form in ink. District Number Probate Court Name 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 SUBSCRIBED AND SWORN TO BEFORE ME Date:__________________ Judge, Clerk, Notary Public, Comm. of Superior Court Affidavit Re Change of Name (Adult) PC-910 REV. 1/14 American LegalNet, Inc. www.FormsWorkFlow.com