Name Change Assistance Application

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Applicant must be 18 years of age or older and a resident of Adams, Bedford, Berks, Blair, Bucks, Bradford, Carbon, Centre, Chester, Clinton, Columbia, Cumberland, Dauphin, Delaware, Fulton, Franklin, Huntington, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montgomery, Montour, Northampton, Northumberland, Perry, Pike, Potter, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York County in Pennsylvania only. Applications from any other locality will be automatically declined.

Applications that are not complete (including sections on income and expenses) may not be considered.

Please provide as much information as possible in the fields below

Financial Aid or Mentoring Application – Name Change

"*" indicates required fields

Is this an application for you or for your minor child? If for a minor child please complete the application using your personal information and then provide details about your child in the "Other Information" section.*
What type of assistance are you seeking?*

Personal Information

Current Legal Name (Parent's name if minor child)*
Chosen Name (if for minor child, please use child's chosen name)*
What is your gender identity?*
Address*
Will this be your address for at least the next four months?*
What is your Race or Ethnicity? (check all that apply)*

Financial Information

Are you receiving or qualify for any of the following assistance programs*
Are you able to provide documentation of sources of income or financial assistance (e.g. W-2, 1099, etc.) This may include copies or screenshots.*
Are you able to provide copies/screenshots of your key expenses (rent, utilities, etc.)?*

Health Care Provider Certifications

Have you received letters from your Healthcare Provider that certify you have undergone appropriate treatment for gender transition? Note: this is required if you intend to change the gender marker on your Pennsylvania Birth Certificate.*
Can you provide a copy of Health Care Provider certifications if requested?*

Other Information

Have you ever applied for a grant from Eastern PA Trans Equity Project in the past?*

Affirmations

Would you like to receive monthly updates on Eastern PA Trans Equity Project's programs, events, and services for the transgender community?
I understand that Eastern PA Trans Equity Project will not be representing me in Court and that I will be representing myself in Court.*
I affirm that the information in this application is true and accurate according to my knowledge.*