Personal Name Change Form Maryland Department Of Labor
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1D
O
P
L
IVISION OF
CCUPATIONAL AND
ROFESSIONAL
ICENSING
B
I
T
P
OARD OF
NDIVIDUAL
AX
REPARERS
rd
500 N. Calvert Street 3
Floor
Baltimore, MD 21202
D
L
, L
R
EPARTMENT OF
ABOR
ICENSING AND
EGULATION
(410) 230-6257
PERSONAL NAME CHANGE FORM
If you are changing your name as a registrant or while in the process of obtaining your
registration you will need to submit a copy of the legal documents (marriage license, divorce
decree, court documents etc.), along with a readable enlarged copy of your driver’s license.
Please fax these items to 410-962-8482, ATTN: Alicia Coar or email to:
Alicia.coar@maryland.gov.
If you would like a new registration card to be sent to you displaying the name change you
will first have to mail the one you have back to us with a written request to: Maryland Board of
Individual Tax Preparers, 500 N. Calvert St. Third Floor, Baltimore, Md. 21202.
Current Name on Record with Board: _______________________________________________________
LAST NAME
FIRST NAME
MIDDLE NAME
You are (check applicable status below)
CURRENT REG. NO.
__________
REGISTRATION APPLICANT
EXAM APPLICANT
Please check one of the items that need to be changed.
1.
Address Change: _________________________________________________________________
NEW ADDRESS STREET
NO.
_________________________________________________________________
CITY
STATE
ZIP CODE
2.
Email Address Change: __________________________________________________
3.
Name Change-In order to change your name you will need to submit this completed form and
a copy of one of the following legal documents:
Marriage license
Divorce decree
Court document
Please include a readable enlarged copy of your driver’s license
The new name as it is to appear in your documents:
_______________________________
_________________________
_____________________
LAST NAME
FIRST NAME
MIDDLE NAME
*Do you request a new license?
_______Yes
______NO
Please return your old registration card to the Board if you want a new one sent to you.
_____________________________
_________________
_____________________________
SIGNATURE
DATE
TELEPHONE NUMBER
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