EFTA00523003.pdf

Affidavit of Common Law Name Change (The following form may be used to confirm your Common law name change for alt Interested parties.) BE IT ACKNOWLEDGED, that the undersigned affiant being of full age and sworn according to law, a resident of New York County, tate of New ork, does hereby depose and state under oath as follows: 1. M name as it appears on my birth certificate and other legal documents is 2. I have used the name based upon common law since September 2008. 3. Accordin I I wish to have my business and legal records reflect the name 4. My change of name has been made in good faith. Said change has not been made in order to avoid creditors or criminal prosecution, nor for any illegal or fraudulent purpose. 5. I am executing this Affidavit in order to assist the appropriate agencies and organizations chosen in all nece Street Address: 301 E. 66m St. Apt. 14G City/State/Zip: New York, NY 10065 Date: January 6, 2009 State of: New York County of: New York On April 28,2009, before me, Harry Beller, personally appeared personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WI Sig Affiant Known Unknown ID Produced (Seal) EFTA00523003