Ctc Form 41 Nc – Fill Out and Use This PDF

DECLARATION OF NAME CHANGE FORM (41-NC)

You may submit a name change at any time using Online Services for Educators on the Commission’s website. There is no additional charge for the name change. If technical problems block you from using the online system to complete the name change, you may submit this Declaration of Name Change Form (41-NC) by postal mail.

Mail to:

Commission on Teacher Credentialing 1900 Capitol Avenue

Sacramento, California 95811-4213

Commission Use Only

Social Security Number:			Date of Birth: (mm/dd/yyyy)
Applicant’s Full Legal Name:
All Former/Maiden Name(s):				County of Employment:
Address:
City:				State:			Zip:
Home Phone:		Work Phone:			Message Phone:
Email Address:

Instructions

To submit a name change to the Commission and verify your true identity by mail, you must send this completed, original Declaration of Name Change form (41-NC) to the Commission office. This application must include your former name and former signature as well as your new name and new signature. You must also include a copy of one of the following items as supporting documentation:

∙social security card

∙passport

∙marriage certificate

∙court order

∙naturalization papers

∙divorce decree

This information may be sent to the Commission by any of these means:

1)fax to 916-327-3166;

2)scan into an email and send to credentials@ctc.ca.gov; or

3)send by postal mail to 1900 Capitol Avenue, Sacramento, CA 95811-4213

Declaration

I have changed my name from: _____________________________________________________________

to: ____________________________________________________________________________________

and hereby request that all records bearing my former name be updated to reflect my new name.

FORM 41-NC 8/13	Page 1 of 2

I certify that the foregoing is true and correct under penalty of perjury.

DATED: ____________________________________ AT: _________________________________________

City or Place

_______________________________________________________________________________________

Signature, Former Name

_______________________________________________________________________________________

Signature, New Name

Important Information

∙Once your records have been reviewed by Commission staff, it is possible that your packet may be returned to you for additional fingerprint information. If this happens, you will be required to submit a copy of a LiveScan receipt (41-LS) verifying you have had your fingerprints taken and have paid the fingerprint processing fees to the LiveScan operator. Out-of-state residents must submit two fingerprint cards (FD-258) in lieu of a LiveScan receipt. When submitting fingerprint cards, a fingerprint processing fee must accompany the returned application.

∙The Commission no longer prints and mails credentials, certificates, and permits. All credentials, certificates, and permits are available through an online view and print process on the Commission’s website at www.ctc.ca.gov.

FORM 41-NC 8/13	Page 2 of 2