SUPERIOR COURT OF CALIFORNIA
COUNTY OF SANTA CLARA
CLETS BACKGROUND INFORMATION FORM
Pursuant to CCP 1279.5, the court is required to conduct a background investigation to determine
whether an applicant for a name change is under the jurisdiction of the California Department of
Corrections or is required to register as a sex offender (PC 290). To conduct this investigation, the
following form must be completed. In the process of completing this form, please print your
information. If any section does not apply to you, please indicate “DNA”.
LAST NAME: FIRST NAME: MIDDLE NAME:
LIST ANY OTHER NAMES THAT YOU USE, INCLUDING MAIDEN NAME, BIRTH NAME OR NICKNAMES:
1.
2.
3.
RESIDENCE: STREET ADDRESS CITY/STATE ZIP PHONE NUMBER:
MAILING ADDRESS IF DIFFERENT FROM RESIDENCE: BUSINESS PHONE:
DATE OF BIRTH: AGE: PLACE OF BIRTH:
(STATE OR COUNTRY)
SEX: HEIGHT: WEIGHT: HAIR: EYES:
DRIVER LICENSE NO.: STATE: EXPIRATION DATE:
SOCIAL SECURITY NO.:
U.S. CITIZEN:
YES
NO
SCARS, MARKS OR TATTOOS: IF YES, DESCRIBE.
I certify the above information is correct.
Signature
Date:
FOR COURT USE ONLY:
CASE NUMBER: _____________________________________
DATE OF APPLICATION: ______________________________
DATE SENT TO SHERIFF: _____________________________
DATE DUE BACK TO SUPERIOR COURT: ________________
HEARING DATE: _____________________________________
PB-4010 REV 4/03 CLETS BACKGROUND INFORMATION FORM Page 1 of 1
(CCP 1279.5 – Name Change)
To keep other people from seeing what you entered on your form please press the
Clear This Form button at the end of the form when finished.
