Form 47870 - Affidavit For Change Of Name - Indiana Professional Standards Board
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1Indiana Professional Standards Board
AFFIDAVIT FOR CHANGE OF NAME
Public and Agency Support Services
251 E. Ohio St., Suite 201
State Form 47870 (R/6-98)
Indianapolis, IN 46204-2133
Telephone: (317) 232-9010
Approved by State Board of Accounts, 1998
Fax: (317) 232-9023
The information in this document is
SOCIAL SECURITY NUMBER
confidential according to IC 5-14-3-4(b)8.
This agency is requesting the disclosure of your
Social Security Number in accordance with IC 4-
1-8-1(a), first paragraph, and with 42 USC
666(a)13. Disclosure is mandatory; this record
cannot be processed without it.
Please Note: This affidavit must be accompanied by the original copy of your currently valid license(s); or if lost or destroyed, a Proof
of Licensing Form completed, and a limited criminal history report. No fee is required.
Please PRINT or TYPE.
STATE OF
}
SS:
COUNTY OF
Name as shown on license(s)
Social Security number
Change Name To:
Full name
Street address
City
State
ZIP code
Date of birth (month, day, year)
Telephone number
License number (if known)
(
)
The undersigned states that on _____________________________________________________ his/her name changed from
Date (month, day, year)
_________________________________________________ to _________________________________________________
and makes this affidavit for the purpose of requesting the Indiana Professional Standards Board change his/her name on the
official records.
I certify that the information and documentation contained in this affidavit are true and accurate to the best of my knowledge and belief.
Signature of applicant
Date signed (month, day, year)
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