RESET

Petition for Change

of Name (Adult) CONNECTICUT PROBATE COURTS
PC-901 REV. 10/17

RECEIVED:

Instructions: 1) An individual 18 years of age or older may use this form to petition for a change of his or her name.
2) The petition must be filed in the court for the probate district in which the petitioner resides and
accompanied by a) PC-910, Affidavit RE Change of Name, b) a certified copy of the petitioner’s long
form birth certificate and c) two forms of identification, one of which must be photographic
identification.
3) The court will conduct a search of the sex offender registry and of the registry of offenders convicted of
crimes with a deadly weapon and may conduct a full criminal background check.
4) For more information, see Probate Court Rules of Procedure sections 47.1 and 47.4.
5) Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed.

Probate Court Name District Number

Petitioner’s
Current Name:
First Middle Last

Petitioner’s Address and Telephone Number Date of Birth Place of Birth

Name on Birth Certificate (if different )

Name to be
Changed to:
First Middle Last

Spouse (Name, address and telephone number.)

The Petitioner represents that:

A change of name is sought for the following reasons:

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 conviction, but solely for the reason(s) stated above.
WHEREFORE, the petitioner requests a change of name to the name stated above.

The representations made in this petition are made under the penalty of false statement.

Signature of Petitioner
Type or Print Name
Date

Petition for Change of Name (Adult) PC-901

CONFIDENTIAL INFORMATION/
Petition for Change of Name
(Adult) PC-901CI REV. 10/17 CONNECTICUT PROBATE COURTS

FOR COURT USE ONLY

RECEIVED:

Probate Court Name District Number

In the Matter of
,an adult

The social security numbers of the following parties are required in connection with this proceeding for change of name:

1) Petitioner:

Name _____________________________________________________________________________________

Social Security Number _______________________________________________________________________

_______________________________________________________________________________________________
Confidential Information/Petition for Change of Name (Adult) PC-901CI
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