LACIV 226 (NEW) NAME CHANGE LASC Approved 10-09 CRIMINAL HISTORY ASSESSMENT Code Civ. Proc., 247 1279.5 C O N F I D E N T I A L STATE BAR NUMBER NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: (Person submitting the application) ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: NAME OF PETITIONER (Person having the name change): Reserved for Clerk222s File Stamp CASE NUMBER: NAME CHANGE CRIMINAL HISTORY ASSESSMENT COURT DATE: Top portion of the form above and number one (1) below to be completed by Petitioner . 1. Number (2) below to be completed by County Probation Department (Code Civ. Proc., 247 1279.5) : 2. Sex Race/Ethnicity Date of Birth Age Social Security Driver222s License or ID Place of Birth Current Address Other name(s) used 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 American LegalNet, Inc. www.FormsWorkFlow.com