NAME CHANGE & CORRECTION OF BIRTH CERTIFICATE

1. Fill out all forms:

Notice of Petition change birth record, Verified Petition change of

birth record, Order changing birth record and request for judicial

intervention (RJI).

2. Verified Petition must be notarized.

3. Take the Verified Petition to County Clerk at 130 Stuyvesant Place

2nd floor and purchase the index number at a cost of $210.00.

Cash is accepted, certified bank check or money order made to

Richmond County Clerk.

4. The County Clerk will keep a copy and give you back the original

verified petition with the index number. The index number should

be placed on all documents? Make a copy of all papers. Also, make

two copies of the front page of the RJI.

5. The Order, RJI, Notice of Petition and Verified Petition need to be

serve on N.Y.C. Department of Health and Corporation Counsel.

This can be done by mail by anyone over the age of 1. 8 who is not

a party to the action. Affidavit of service must be completed and

notarized by server.

6. The RJI, Verified Petition and Notice of Petition (with copies of

front pages) should be taken to the Supreme Court at 26 Central

Avenue, the Civil Term Office room 131 where you will pay

$95.00. (Adjacent window is another office of County Clerk where

payment is acceptable.)

Instructions: Fill in the box below and the index number. Complete the blank spaces printed in bold

below in accordance with the directions given

PLEASE TAKE NOTICE that, upon the Verified Petition of ,

verified the ,the petitioner will move this court in the

Motion Support Courtroom, Room 126 at the courthouse, 26 Central Ave, Staten Island, New

York, on the at 9:30 A.M., for an order to change,

amend or correct the records of the Bureau of Vital Statistics, New York City Department of

Health, in refernce to a birth record, as follows:

SUPREME COURT OF THE STATE OF NEW YORK

COUNTY OF RICHMOND

In the Matter of the Application of

Petitioner,

For leave to change, amend or correct the records of the Bureau of Vital Statistics, New York City Department of Health

- against-

BUREAU OF VITAL STATISTICS, NEW YORK CITY

DEPARTMENT OF HEALTH,

Respondent.

Index Number

NOTICE OF PETITION

CHANGE OF BIRTH RECORD

Dated:

To:

New York, New York 10007100 Church StreetNYC Corporation Counsel

Long Island City, New York 11101

42-09 28th Street

New York City Department of Health

TO THE SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF RICHMOND

The petition of respectfully shows to this Court as follows:

1. Your petitioner resides at

.

2. The respondent is the Bureau of Vital Statistics of the New York City Department

of Health. The Bureau is responsible of the maintenance of birth records in the City of New

York.

3.

SUPREME COURT OF THE STATE OF NEW YORK

COUNTY OF RICHMOND

In the Matter of the Application of

Petitioner,

For leave to change, amend or correct the records of the Bureau of Vital Statistics, New York City Department of Health

- against-

BUREAU OF VITAL STATISTICS, NEW YORK CITY

DEPARTMENT OF HEALTH,

Respondent.

Index Number

VERIFIED PETITION

CHANGE OF BIRTH RECORD

4. The following change/correction/amendment in a birth record is sought by this

proceeding for the reasons which follow.

5. Attached hereto as Exhibit A is a certified copy of my birth certificate. [Attach the

same]

6. Attached hereto as Exhibit B is a copy of one or more items of proof showing that

I am the person named in the birth certificate, namely

7. A prior application been made for the relief requested herein

WHEREFORE, your petitioner prays that this Court :

Dated: New York, New York ___________________________

Petitioner

________________, 20____ [SIGN YOUR NAME BEFORE

A NOTARY PUBLIC]

YOU MUST SIGN YOUR NAME TO THIS PAGE AND TO THE ATTACHED PAGE (THE

“VERIFICATION” PAGE) IN FRONT OF A NOTARY PUBLIC.

VERIFICATION

STATE OF NEW YORK)

ss:

COUNTY OF NEW YORK)

, being duly sworn, deposes and says: That I am the petitioner in

this proceeding; that I have read the foregoing petition and know the contents thereof; that the

same is true to my own knowledge, exept as to matters therein stated to be alleged on

information and belief; and that as to those matters I believe then to be true.

___________________________

Petitioner [SIGN YOUR NAME BEFORE

A NOTARY PUBLIC]

Sworn to before me this

____ day of ________________ , _________

______________________________

Notary Public

Instructions: Fill in the box below and the index number. Complete the fillable sections of this document

in accordance with the directions given. (Other Spaces are for Court use only)

Upon reading and filing the petition of , verified the

, the annexed certified copy of the

birth certificate of the applicant, and the parties having been heard on ________________, or no

one having appeared in opposition thereto, it is

ORDERED that the application is granted and the birth record of the petitioner

PRESENT: HON. _____________________________

Justice of this Supreme Court

In the Matter of the Application of

Petitioner,

For leave to change, amend or correct the records of the Bureau of Vital Statistics, New York City Department of Health

- against-

BUREAU OF VITAL STATISTICS, NEW YORK CITY

DEPARTMENT OF HEALTH,

Respondent.

Index Number

ORDER CHANGING

BIRTH RECORD

At IAS part ____ of the

Supreme Court of the State of

New York held in and for the

County of Richmond at the

County Courthouse thereof, 26

Central Avenue, Staten Island

NY 10301 on the _____ day of

_____________ , _________

is corrected/amended/changed to state as follows:

and it is further

ORDERED that the petitioner shall file a certified copy of this order (which may be

obtained from the Office of the County Clerk ( ) with the Bureau of Vital Statistics,

New York City Department of Health, 125 Worth Street, New York, New York, which shall

amend the official records pertaining to the aforesaid birth in accordance with this order.

Enter:

_____________________________

J.S.C.

REQUEST FOR JUDICIAL INTERVENTION UCS-840

(rev. 07/29/2019)

_______________ COURT, COUNTY OF _______________

Index No: _______________ Date Index Issued: _______________ For Court Use Only:

CAPTION Enter the complete case caption. Do not use et al or et ano. If more space is needed, attach a caption rider sheet. IAS Entry Date

Plaintiff(s)/Petitioner(s) Judge Assigned -against-

RJI Filed Date

Defendant(s)/Respondent(s)

NATURE OF ACTION OR PROCEEDING Check only one box and specify where indicated. COMMERICIAL MATRIMONIAL

Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.) Contested

Contract NOTE: If there are children under the age of 18, complete and attach the

Insurance (where insurance company is a party, except arbitration) MATRIMONIAL RJI ADDENDUM (UCS-840M).

UCC (includes sales and negotiable instruments) For Uncontested Matrimonial actions, use the Uncontested Divorce RJI (UD-13).

Other Commercial (specify): _____________________________________________ TORTS

NOTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202.70(d), Asbestos

complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C). Child Victims Act

REAL PROPERTY Specify how many properties the application includes: _______ Environmental (specify): _______________________________________________

Condemnation Medical, Dental or Podiatric Malpractice

Mortgage Foreclosure (specify): Residential Commercial Motor Vehicle

Property Address: ____________________________________________________ Products Liability (specify): ____________________________________________

NOTE: For Mortgage Foreclosure actions involving a one to four-family, Other Negligence (specify): ____________________________________________

owner-occupied residential property or owner-occupied condominium, Other Professional Malpractice (specify): _________________________________

complete and attach the FORECLOSURE RJI ADDENDUM (UCS-840F). Other Tort (specify): __________________________________________________

Tax Certiorari

Tax Foreclosure

Other Real Property (specify): ___________________________________________

OTHER MATTERS

Certificate of Incorporation/Dissolution [see NOTE in COMMERCIAL section]

Emergency Medical Treatment

Habeas Corpus

Local Court Appeal

Mechanic’s Lien

Name Change

Pistol Permit Revocation Hearing

SPECIAL PROCEEDINGS

CPLR Article 75 (Arbitration) [see NOTE in COMMERCIAL section]

CPLR Article 78 (Body or Officer)

Election Law

Extreme Risk Protection Order

MHL Article 9.60 (Kendra’s Law)

MHL Article 10 (Sex Offender Confinement-Initial)

MHL Article 10 (Sex Offender Confinement-Review)

MHL Article 81 (Guardianship)

Other Mental Hygiene (specify): ________________________________________ Other Special Proceeding (specify): ______________________________________

Sale or Finance of Religious/Not-for-Profit Property

Other (specify): ______________________________________________________

STATUS OF ACTION OR PROCEEDING Answer YES or NO for every question and enter additional information where indicated. YES NO

Has a summons and complaint or summons with notice been filed? If yes, date filed:

Has a summons and complaint or summons with notice been served? If yes, date served:

___________________ ___________________

Is this action/proceeding being filed post-judgment? If yes, judgment date: ___________________

NATURE OF JUDICIAL INTERVENTION Check one box only and enter additional information where indicated.

Return Date: ___________________ Return Date: ___________________ Return Date: ___________________

Infant’s Compromise

Extreme Risk Protection Order Application

Note of Issue/Certificate of Readiness

Notice of Medical, Dental or Podiatric Malpractice Notice of Motion

Notice of Petition

Order to Show Cause

Other Ex Parte Application

Date Issue Joined: ___________________

Relief Requested: ______________________________ Relief Requested: ______________________________ Relief Requested: ______________________________ Relief Requested: ______________________________

Poor Person Application

Request for Preliminary Conference

Residential Mortgage Foreclosure Settlement Conference

Writ of Habeas Corpus

Other (specify): ____________________________________________________________________________

RELATED CASES List any related actions. For Matrimonial cases, list any related criminal or Family Court cases. If none, leave blank. If additional space is required, complete and attach the RJI ADDENDUM (UCS-840A).

Case Title Index/Case Number Court Judge (if assigned) Relationship to instant case

PARTIES For parties without an attorney, check the “Un-Rep” box and enter the party’s address, phone number and email in the space provided. If additional space is required, complete and attach the RJI ADDENDUM (UCS-840A).

Un-Rep

Parties List parties in same order as listed in the caption and indicate roles (e.g., plaintiff, defendant, 3rd party plaintiff, etc.)

Attorneys and Unrepresented Litigants For represented parties, provide attorney’s name, firm name, address, phone and email. For unrepresented parties, provide party’s address, phone and email.

Issue Joined For each defendant, indicate if issue has been joined.

Insurance Carriers For each defendant, indicate insurance carrier, if applicable.

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

Name:

Role(s): YES NO

I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR PROCEEDINGS,

EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION BEEN PREVIOUSLY FILED IN THIS ACTION OR PROCEEDING.

Dated: ___________________ _______________________________________________________ Signature

________________________________________________________ _______________________________________________________ Attorney Registration Number Print Name

NAME CHANGE AND CORRECTION OF BIRTH

CERTIFICATE

REQUEST FOR JUDICIAL INTERVENTION (RJI)

BACK PAGE (PAGE 2) SHOULD BE FILL OUT

WITH THE FOLLOWING INFORMATION:

1: UNREPRESENTED PARTIES YOUR NAME AND ADDRESS

2: NEW YORK CITY DEPARTMENT OF HEALTH 42-09 28th

STREET, LONG ISLAND CITY NY 11101

3: NEW YORK CITY CORPORATION COUNSEL 100 CHURCH

STREET NEW YORK NY 10007