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Contra Costa California Form 1125-A: What You Should Know

NOTE: Certificated names are not made available as a separate document, but rather incorporated into the person's signature line. The Name is not changed and will not appear when signed and a certified copy of a copy of the certificate is provided. PERSONAL INFORMATION • Applicant Name: name of applicant • Personal information (First and Last) — First Names, Middle Names, Family, or other name(s) with which the applicant has ever been associated • Telephone # (1) if applicant is a corporation or partnership • Address where applicant was formerly domiciled • Date of birth of Applicant • Social Security Number or other information • Home Address • Driver License # • Social Security Number • California Identification Number if applicant is a citizen of the United States or alien  and applicant resides in California • Citizenship, Alienate — United States and alien status • Federal Employment Authorization Card # or SSN (if in U.S.) • Signature line (if applicable, and if any) (only for adults, the signature line may be used. If the applicant is not at least 18, a written signature page is required. For children and teenagers with limited English Proficiency, a signed statement identifying their parent(s) in the U.S. is required.

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