LA SC CIV 226 Rev . 10 /18 NAME CHANGE CRIMINAL HISTORY ASSESS MENT Code Civ. Proc., 247 1279.5 For Mandatory Use C O N F I D E N T I A L NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: (Person submitting the application) ATTORNEY FOR (Name): STATE BAR NUMBER Reserved for Clerk222s File Stamp SUPERIOR COURT OF CALIF ORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: NAME OF PETITIONER (Person having the n ame c hange): NAME CHANGE CRIMINAL HISTORY ASSESSMENT CASE NUMBER: COURT DATE: PETITIONER: Please complete the top portion of the form. PROBATION DEPARTMENT: Please complete the bottom portion of the form: Sex Race/Ethnicity Date of Birth Age Social Security Driver222s License or ID P lace of Birth Current Address Other name(s) used PTD Application No. An automated search of the criminal history information data systems reveals the following: is required to register as a sex offender pursuant to Section 290 of the Penal Code. OR is not a registered sex offender. Comments: Date: By: INVESTIGATOR / AIDE PROBATION DEPARTMENT PRETRIAL SERVICES DIVISION (213) 974 - 5821 American LegalNet, Inc. www.FormsWorkFlow.com