Fillable Form -4213: Request to Change Name or Personal (California)

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Form -4213: Request to Change Name or Personal (California)

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FORM 41-NC 5/2018
Page 1 of 2
State of California
Commission on Teacher Credentialing
Certification Division
1900 Capitol Avenue
Sacramento, CA 95811
-4213
CTC Use Only
Initials:
No change needed
Change needed:
SSN DOB Name
Request to Change Name or Personal Profile
Use this form to submit changes or corrections to your personal information on file with the Commission. First, complete
Section A, Personal Information. If you are updating your SSN or ITIN, complete Section B. If you are updating your Date of
Birth, complete Section C. If you are updating the name the Commission has on file for you, complete Section D. This form is
only valid if it has your signature and date of signature at the bottom of page 2. Incomplete or illegible forms or supporting
documents will be not be processed. All supporting documents become property of the Commission.
A. PERSONAL INFORMATION (required)
Current Full Legal Name (Print):
Social Security (SSN) or Individual Tax ID Number (ITIN):
Date of Birth (mm/dd/yyyy):
Mailing Address:
City:
State:
Home Phone:
Work Phone:
Message Phone:
Email Address:
CHANGES TO YOUR MAILING OR EMAIL ADDRESS CANNOT BE COMPLETED USING THIS FORM;
ADDRESS CHANGES MUST BE COMPLETED ONLINE.
B. COMPLETE THIS SECTION FOR SSN/ITIN CHANGE/CORRECTION
My full legal name:
_______________________________\____________________________________\_______________________________________
First Middle
Last
Information p
reviously submitted to the Commission (if known): SSN/ITIN _________-_______-_________
Request SSN/ITIN to be changed to: _________-_______-_________
To verify S
SN/ITIN - YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE SSN/ITIN CHANGE/CORRECTION
Complete 41-NC sections A and B, sign and date
Copy of Social Security Card or ITIN
Copy of valid government issued ID (driver’s license, military ID card, Permanent Resident card, etc.)
C. COMPLETE THIS SECTION FOR DATE OF BIRTH CORRECTION
My full legal name:
_______________________________\____________________________________\_______________________________________
First
Middle
Last
Infor
mation previously submitted to the Commission (if known): Date of Birth ______________ _______ _________
Month Date Year
Request Date of B
irth to be corrected to: ______________ _______ _________
Month Date Year
Verify Date of Birth - YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE DATE OF BIRTH CORRECTION
Complete 41-NC sections A and C, sign and date
Copy of valid government issued ID (driver’s license, passport, military ID card, Permanent Resident card, etc.)
________
FORM 41-NC 5/2018
Page 2 of 2
D. COMPLETE THIS SECTION FOR NAME CHANGE
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 Live Scan
receipt (41-LS) verifying you have had your fingerprints taken and have paid the fingerprint processing fees to
the Live Scan operator. Out-of-state residents must submit two fingerprint cards (FD-258) in lieu of a Live Scan
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.
______________
____________________________________________ ________________________
Mail to:
Commission on Teacher Credentialing
Certification Division
ATTN: Educator Profile Change Request
1900 Capitol Avenue
Sacramento, California 95811-4213
Former full legal name (name the Commission currently has on file):
__________
_____________________\____________________________________\_______________________________________
First Middle Last
I re
quest m
y name be changed to:
____________
___________________\____________________________________\_______________________________________
First Middle Last
NA
ME ch
anged due to:
Marriage – YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE NAME CHANGE
Complete 41-NC sections A and D, sign and date
Copy of endorsed marriage certificate
Copy of Social Security Card or ITIN stating married name
Copy of valid government issued ID with new name (driver’s license, military ID card, Permanent Resident card, etc.)
Superior Court – YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE NAME CHANGE
Complete 41-NC sections A and D, sign and date
Certified copy of completed, endorsed Decree of Changing Name
Copy of Social Security Card or ITIN stating new name
Copy of valid government issued ID with new name (driver’s license, military ID card, Permanent Resident card, etc.)
Dissolution of Marriage – YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE NAME CHANGE
Complete 41-NC sections A and D, sign and date
Copy of Dissolution (endorsed) which states “the former name restored,” and/or endorsed copy of Ex Parte Application for
Restoration of Former Name
Copy of Social Security Card or ITIN stating new name
Copy of valid government issued ID with new name (driver’s license, military ID card, Permanent Resident card, etc.)
Citizenship – YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE NAME CHANGE
Complete 41-NC sections A and D, sign and date
Copy of Certificate of Naturalization
Copy of Social Security Card or ITIN stating new name
Copy of valid government issued ID with new name (driver’s license, military ID card, Permanent Resident card, etc.)
Correction – YOU MUST PROVIDE ALL OF THE FOLLOWING BEFORE WE CAN PROCESS THE NAME CHANGE
NOTE: Corrections are for misspellings and typos only
Complete 41-NC sections A and D, sign and date
Copy of valid government issued ID with correct name (driver’s license, military ID card, Permanent Resident card, etc.)
Signature Date:
By sig
ning this document, I authorize the Certification Division to make the changes indicated above with the
Commission on Teacher Credentialing, and certify that the foregoing is true and correct under penalty of perjury.
For processing, send this completed form and all required supporting documentation to the Commission at:
Commission on Teacher Credentialing
Certification Division
1900 Capitol Avenue
Sacramento, CA 95811-4213
ATTN: Educator Profile Change Request
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Form -4213: Request to Change Name or Personal (California)

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Completed 12 January 2022

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