Form 47870 - Affidavit For Change Of Name - Indiana Department Of Education
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INDIANA DEPARTMENT OF EDUCATION
AFFIDAVIT FOR CHANGE OF NAME
OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT
151 West Ohio Street
State Form 47870 (R8 / 4-09)
Indianapolis, IN 46204
Approved by State Board of Accounts, 2007
Toll Free: 1-866-542-3672
Fax: (317) 232-9023
The information in this document is 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 RESIDENCE
COUNTY OF RESIDENCE
Name as shown on license(s)
Social Security number *
Change Name To:
Full name
Street address (number and street)
City
State
ZIP code
Telephone number
E-mail Address
(
)
License number (if known)
Date of birth (month, day, year)
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 Department of Education / Office of Educator Licensing and
Development to 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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