Amador — CIV-136

Source: https://amador.courts.ca.gov/system/files/civ-136cletsbackgroundinfo.pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF AMADOR

CLETS BACKGROUND INFORMATION FORM NAME CHANGE

Pursuant to CCP 1279.5, the court is required to conduct a background investigation to determine whether an applicant for a name change is under the jurisdiction of the California Department of Corrections or is required to register as a sex offender (PC 290). To conduct this investigation, the following form must be completed. In the process of completing this form, please print your information. If any section does not apply to you, please indicate “DNA”.

LAST NAME: FIRST NAME: MIDDLE NAME:

LIST ANY OTHER NAMES THAT YOU USE, INCLUDING MAIDEN NAME, BIRTH NAME OR NICKNAMES:

RESIDENCE: STREET ADDRESS CITY/STATE ZIP PHONE NUMBER:

MAILING ADDRESS IF DIFFERENT FROM RESIDENCE BUSINESS PHONE:

DATE OF BIRTH: AGE: PLACE OF BIRTH: SEX: HEIGHT: WEIGHT: HAIR: EYES: (STATE OR COUNTRY)

DRIVER LICENSE NO.: STATE: EXPIRATION DATE: US CITIZEN

YES NO

I AM UNDER THE JURISDICTION OF THE DEPARTMENT OF I AM REQUIRED TO REGISTER AS A SEX OFFENDER CORRECTIONS YES NO PURSUANT TO PENAL CODE 290 CDC NUMBER________________________ YES NO

I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct.

Signature: ___________________________________________________________________________ Date: _____________________________

CIV-136 CLETS BACKGROUND INFORMATION FORM WWW.AMADORCOURT.ORG NEW 04/17/2017 (CCP 1279.5 – NAME CHANGE)