County Clerk, Beardson County Application for INDEX NUMBER

Pursuant to CPLR 306-a

Index Number:
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TITLE OF ACTION OR PROCEEDING Supreme Court, Beardson County Legal Name Change of Dorian D. Rothschild

Petitioner: Dorian D. Rothschild 35 Palm Circle Dr. Buffalo, New York, 40432

Indexed and Entered (Do not write on line above.)

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INDEX NUMBER FEE $ 210.00

Supreme Court, Beardson County

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Legal Name Change of Dorian D. Rothschild

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SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF BEARDSON

______________________________________________ IN THE MATTER OF THE APPLICATION OF Dorian D. Rothschild, PETITIONER, FOR LEAVE TO CHANGE HIS/HER NAME TO: PETITION FOR A NAME CHANGE Index #__________

Dorian D. Louis III

______________________________________________ TO THE SUPREME COURT OF THE STATE OF NEW YORK: The Petition of Dorian D. Rothschild respectfully shows this court: 1. The petitioner resides at 35 Palm Circle Dr., in the city of Buffalo, County of Beardson, and has so resided for a period of 5 years and 3 months prior to the making of this application. 2. The petitioner, Dorian D. Rothschild, was born at Marin General Hospital, in Kentfield, United States on March 23, 1988 and is now 24 years of age. (Attached hereto and made a part hereof is a copy of the petitioner's birth certificate.) 3. The Petitioner proposes to change said his/her name to Dorian D. Louis III. 4. The petitioner is a natural born citizen of the United States. 5. The petitioner is not married and has not been married previously. 6. The petitioner X has never been convicted of a crime. has been convicted of a crime, the details of which are attached in a separated statement, annexed hereto and made a part hereof. 7. The petitioner has never been adjudicated a bankrupt 8. There are no judgments or liens of record and no actions pending against your in petitioner in any court of this state or of the United States, or of any governmental subdivision thereof, or elsewhere, whether the court be of record or not

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9. There are no bankruptcy or insolvency proceedings, voluntary or involuntary, pending against your petitioner in any court whatsoever or before any officer, person, body or board having jurisdiction thereof and your petitioner has not, at any time, made any assignments for the benefit of creditor 10. The petitioner is not responsible for child support obligations. (If there are child support obligations, details are attached in a separate statement). 11. The petitioner is not responsible for spousal support obligations. (If there are spousal support obligations, details are attached in a separate statement. 12. The grounds of this application to change the petitioner's name are as follows: I hate my father, who walked out on my mom and I when I was 5. 13. No previous application has been made for the relief sought herein. WHEREFORE, petitioner respectfully prays for an order permitting the petitioner Dorian D. Rothschild to assume the name Dorian D. Louis III in place of that of Dorian D. Rothschild

DATED: ______________________, 20___. ___________________________________ Dorian D. Rothschild ____________________________________________________________________________________ STATE OF NEW YORK ) ss.:

INDIVIDUAL VERIFICATION

COUNTY OF BEARDSON ) THIS IS TO CERTIFY that I, _____________________________ being duly sworn deposes and says: your deponent is the Petitioner in the within action; your deponent has read the foregoing Petition and knows the contents thereof. The same is true to deponents own knowledge, except as to the matters therein stated to be alleged on information and belief, and as to those matters deponent believes it to be true. Sworn to before me this _____ day of ____________, 20___. ____________________________________ Petitioner _____________________________ Notary Public

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SUPPLEMENTAL STATEMENT TO PETITION FOR A NAME CHANGE FOR Dorian D. Rothschild

Criminal Convictions

Family Support Obligation

_________________

____________________________________________________________________________________ STATE OF NEW YORK ) ss.:

INDIVIDUAL VERIFICATION

COUNTY OF BEARDSON ) THIS IS TO CERTIFY that I, _____________________________ being duly sworn deposes and says: your deponent is the Petitioner in the within action; your deponent has read the foregoing Statement and knows the contents thereof. The same is true to deponents own knowledge, except as to the matters therein stated to be alleged on information and belief, and as to those matters deponent believes it to be true. Sworn to before me this _____ day of ____________, 20___. ____________________________________ Petitioner _____________________________ Notary Public

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At a _______Term, Part __ of the ______ Court of the State of New York, held in and for the County Of __________, ______________, _____________, New York on the ________day of ________, 20___. PRESENT: HON. _______________________________ IN THE MATTER OF THE APPLICATION OF DORIAN D. ROTHSCHILD NAME CHANGE ORDER FOR LEAVE TO CHANGE HIS/HER NAME TO: INDEX NO._____________

DORIAN D. LOUIS III

Upon reading and filing the petition of Dorian D. Rothschild verified the ______ day of _________, 20___ praying for leave to change his name/her name to Dorian D. Louis III and the court being satisfied thereby that petition is true and that there is no reasonable objection to the change of name proposed. Now on motion of Dorian D. Rothschild, Petitioner, it is ORDERED that the petitioner, Dorian D. Rothschild, having been born in the City of Kentfield, County of Marin General Hospital, United States, Birth certificate # 123456789 shall be known by the name Dorian D. Louis III which he/she is hereby authorized to assume, and it is further ORDERED that this order shall be entered and the papers upon which it was granted shall be filed, prior to the publication hereinafter directed, in the office of the Clerk of the County of Beardson, wherein petitioner resides, and it is further ORDERED that at least once within sixty days after the making of this order, a notice in substantially the following form, prescribed by article 6 of the civil rights law of the State of New York shall be published in the New York Times newspaper, a newspaper published in the said County of Beardson: Notice is hereby given that an order entered by the Supreme Court Beardson County, on the _____ day of ________, 20__, bearing Index No. ____________, a copy of which may be examined at the office of the clerk, located at ________________, _______________, N.Y. grants me the right, to assume the name Dorian D. Louis III. My present address is 35 Palm Circle Dr., Buffalo, New York 40432; My date of birth is March 23, 1988; My present name is Dorian D. Rothschild; and it is further
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ORDERED that proof of publication as heretofore directed shall be filed in the office of the Beardson County Clerk within 90 days after the signing of this order, and it is further ORDERED that upon full compliance with the provisions of this order, petitioner shall be known by the name Dorian D. Louis III which he/she is authorized to assume, and by no other name. ENTER ___________________________________ J.S.C.

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LETTER TO NEWSPAPER

DATE:

New York Times Newspaper 1000 Madison Ave. New York, New York 50554

Dear Sir or Madam: Re: Name Change Notice of Dorian D. Rothschild Please print the following Notice in your newspaper one time. After publication has been completed, please send the Certificate of Publication to me in the enclosed self addressed stamped envelope. Notice is hereby given that an order entered by the Supreme Court, Beardson county, on the ___ day of ___, bearing Index Number __________, a copy of which may be examined at the office of the clerk, located at_____________________________,_____________, NY _______, in room number ____, grants me the right to assume the name of Dorian D. Louis III, the date of my birth is March 23, 1988, the place of my birth is Kentfield, Marin General Hospital, my present name is Dorian D. Rothschild. Please bill me for the cost of publication. If you have any questions, please feel free to contact me. I thank you for your cooperation. Sincerely, Dorian D. Rothschild 35 Palm Circle Dr. Buffalo, New York, 40432 (404) 305-1234

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