Name Change Criminal History Assessment
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1C O N F I D E N T I A L
NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NUMBER
(Person submitting the application)
Reserved for Clerk’s File Stamp
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
COURTHOUSE ADDRESS:
NAME OF PETITIONER (Person having the name change):
CASE NUMBER:
NAME CHANGE
COURT DATE:
CRIMINAL HISTORY ASSESSMENT
Top portion of the form above and number one (1) below to be completed by Petitioner.
1.
Sex
Race/Ethnicity
Date of Birth
Age
Social Security
Driver’s License or ID
Place of Birth
Current Address
Other name(s) used
Number (2) below to be completed by County Probation Department (Code Civ. Proc., § 1279.5):
2.
PTD Application No.___________________________
An automated search of the criminal history information data systems reveals the following:
□
□
Petitioner is a registered sex offender.
Petitioner is not a registered sex offender.
and/or
□
□
Petitioner is under the Jurisdiction
Petitioner is not under the Jurisdiction
of the Department of Corrections.
of the Department of Corrections.
□
Petitioner unable to be identified.
□
Comments:________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Date:__________________________
By: ________________________________________
INVESTIGATOR / AIDE
PROBATION DEPARTMENT PRETRIAL SERVICES DIVISION
(213) 974-5821
NAME CHANGE
LACIV 226 (NEW)
CRIMINAL HISTORY ASSESSMENT
LASC Approved 10-09
Code Civ. Proc., § 1279.5
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