Form Pc-910a - Affidavit Re Change Of Name (Minor) - Connecticut Probate Courts
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Affidavit Re Change of Name (Minor)
C O N N E C T I C U T P R O B A T E C O U R T S
PC-910A REV. 1/14
R E C O R D E D :
R E C E I V E D :
1)
Submit with form PC-900, Petition for Change of Name (Minor).
Instructions:
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 of the above-named minor as next friend.
2. The minor presently lives at _____________________________________________________________ and has
been a resident of _________________________________Connecticut for ______ years.
3. The minor owns real estate located in ________________________________________.
4. The minor does not have any outstanding debts that are in arrears. I will notify any creditors of the change of
name of the minor.
5.
A. There are no criminal charges pending against the minor.
B. There are criminal charges pending against the minor as described below:
C. The minor has never been convicted of any offense.
D. The minor has been convicted of a criminal offense(s) as described below:
Due to the nature of the minor’s offense, the minor is obligated to register on the Sex Offender
Registry, and, prior to filing this petition with the court, the commissioner of emergency services and
public protection was notified in accordance with C.G.S. section 45a-99.
Due to the nature of the minor’s offense, the minor is obligated to register on the Deadly Weapons
Offender Registry, and, prior to filing this petition with the court, the commissioner of emergency services
and public protection was notified in accordance with C.G.S. section 45a-99.
6. The purpose of the change of name of the minor is not to deceive, defraud or mislead any person or
governmental agency, nor to avoid the legal consequences of a criminal conviction.
7. There
has
has not been a previous petition 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 (Minor)
-910A REV. 1/14
PC
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