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Application for Change of Name (Adult)

To apply for a legal name change in Connecticut, interested individual must submit this form to the county court clerk’s office along with the Name Change Affidavit and a check for the required filing fee.

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APPLICATIONFOR
CHANGE OFNAME (ADULT)
PC-901 REV.7/12 STATE
OFCONNECTICUT
DATEOFAPPLICATION
PETITIONER [Give present nameandnew name asrequested. ]
SPOUSE [
Give present nameandnew name asrequested. ]
The petitioner(s) represent(s) that the purpose of seeking a change \
of name is not to deceive, defraud, or mislead any person or 
governmental agency, nor to avoid the legal consequences of a criminal c\
onviction, but solely for the reason(s) stated above. 
WHEREFORE, thepetitioner(s) asindicated above,request(s) achange ofname tothe name(s) statedabove.
SIGNED: PETITIONER..............................................................\
.................................     Date:
CO-PETITIONER ........................................................................\
..............................       Date:The
representations containedhereinaremade under thepenalties offalse statement.
APPLICATION FORCHANGE
IN
RE CHANGE OFNAME OF
Achange ofname issought forthefollowing reasons:
OF NAME (ADULT)
PC-901 CO-PETITIONER	
COURT
OFPROBATE
TO: COURT OFPROBATE, DISTRICTNO.
[
orprint inblack ink.]
Type
[ Attach PC-910, Affidavit Re Change of Name .]
DATE OF BIRTH AND PLACE OF BIRTH: NAME ON BIRTH CERTIFICATE:
PRESENT ADDRESS/ TEL. NO.: HOW LONG HAS PETITIONER LIVED THERE?NAME AND ADDRESS OF NON-PETITIONING SPOUSE, IF ANY:
DATE OF BIRTH AND PLACE OF BIRTH: NAME ON BIRTH CERTIFICATE:
PRESENT ADDRESS/ TEL. NO.:
HOW LONG HAS CO-PETITIONER LIVED THERE? Complete Confidential Information Sheet for PC-901 on next page.
]	
NAME:	First
Middle	Last	
CHANGED TO:	First	Last	Middle	
NAME:	FirstMiddle	Last	
CHANGED TO:	First	Last	Middle

CONNECTICUT PROBATE COURTS	 	
CONFIDENTIAL INFORMATION/	 	
Petition for Change of Name (Adult) 
PC	-901C  NEW 10/16	  FOR COURT USE ONLY 	
 	RECEIVED
: 
Probate Court Name    District Number 
In the Matter of              	
 , an adult. 	
The soc

ial security numbers of the following parties are required in connection with this proceeding  for change of name: 
1) Peti

tioner:
Name   ________________________________________________________________________\
_____________

 
Soci

al Security Number   _______________________________________________________________________ 
2) Spous

e/Co-Petitioner:
Name   ________________________________________________________________________\
_____________

 
Soci

al Security Number   _______________________________________________________________________ 
_______________________________________________________________________________________________  
Confidential Information/Petition for Change of Name (Adult)                                                                             PC-901C
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