Free 47870.FH11 - Indiana

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AFFIDAVIT FOR CHANGE OF NAME
State Form 47870 (R8 / 4-09) Approved by State Board of Accounts, 2007

INDIANA DEPARTMENT OF EDUCATION OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT 151 West Ohio Street Indianapolis, IN 46204 Toll Free: 1-866-542-3672 Fax: (317) 232-9023 www.doe.in.gov/educatorlicensing

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)