CLETS FormCal. Super. - 6th Dist.April 6, 2021SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA CLETS BACKGROUND INFORMATION FORM NAME CHANGE 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 0f the California Department of Corrections or is required t0 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 t0 you, please indicate "DNA". LAST NAME: ; FIRST NAME: MIDDLE NAME: i ARCE i EMILIA JEANINE LIST ANY OTHER NAMES THAT YOU USE, INCLUDING MAIDEN NAME, BIRTH NAME 0R NICKNAMES: 1. EMILIA LANéELLOTTI 2. l | 3. ! RESIDENCE: ;STREET ADDRESS CITYISTATE ZIP PHONE NUMBER: 5397 VAUXHALL CIR SAN JOSE CA 95136 408-483-9830 MAILING ADDRESS IF DIFFERENT FROM RESIDENCE: BUSINESS PHONE: DATE OF BIRTH: i AGE: PLACE 0F BIRTH: SEX: HEIGHT: WEIGHT: HAIR: EYES: I (STATE 0R COUNTRY) 01/01/2003 18 CA F 5'4 130 BLK BRN DRIVER LICENSE NO.: STATE: EXPIRATION DATE: SOCIAL SECURITY NO.: U.S. CITIZEN: NIA 609-37-3922 YES m NO D SCARS, MARKS OR TATTOOS: IF YES, DESCRIBE. l certify the above information is correct. Signature Date: 4I612021 FOR COURT USE ONLY21 C V 3 7 9 5 DATE SENT TO SHERIFF: CASE NUMBER: 1 4 DATE DUE BACK TO SUPERIOR COURT: DATE OF APPLICATION: APR D 6 2021 HEARING DATE: gé/O/I/J'O-l/ PB-4o1OREV 4/03 CLETS BACKGROUND INFORMATION FORM Page1 on (CCP 1970 S _ Mama Channn\
