Form Hcs 105 - Home Care Aide Registry Request For Name/address Change

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CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

HOME CARE SERVICES BUREAU

HOME CARE AIDE REGISTRY REQUEST FOR NAME/ADDRESS CHANGE

Pursuant to California Health and Safety Code section 1796.28(a)(2) Home Care Aide applicants must to notify the Department of an

address change within 10 days. Please type or print clearly. Please note that submission of this form will serve as notification of name

and or address change to only the Home Care Aide Registry and the Home Care Services Bureau. Please ensure that you include a

copy of one of the following forms of identification: California Driver’s License, California ID Card, Permanent Residence Card, or a

numbered, picture ID issued from a state other than California. Mail this form and a copy of your identification to: The California Depart-

ment of Social Services, Home Care Services Bureau 744 P Street, MS T8-3-90, Sacramento, CA 95814. Please note that incomplete

packets will not be accepted.

Change of Address (complete sections I, II, & IV)

Name Change (complete sections I, III & IV)

SECTION I -- CURRENT INFORMATION

FIRST NAME

LAST NAME

MIDDLE NAME

PER ID/HCA ID NUMBER

DATE OF BIRTH

AREA CODE/TELEPHONE NUMBER

MAILING ADDRESS (NUMBER AND STREET)

(

)

CITY

ZIP CODE

STATE

SECTION II: CHANGE OF ADDRESS

PREVIOUS MAILING ADDRESS (NUMBER AND STREET)

AREA CODE/TELEPHONE NUMBER

(

)

CITY

ZIP CODE

SECTION III: NAME CHANGE

The California Department of Social Services may recognize a name change by a registered Home Care Aide if that

name is now his or her legal name for all purposes and if the change is not made for fraudulent purposes and is not

misleading to the public.

Please submit a photocopy of the legal documentation with this form for name changes. This document must show your

current and previous name. Acceptable forms of legal documentation are one of the following: Marriage Certificate,

Dissolution of Marriage (Divorce Decree), or Certified Court Order.

PREVIOUS LAST NAME (LAST NAME)

PREVIOUS FIRST NAME

PREVIOUS MIDDLE NAME

I declare under penalty of perjury under the laws of the State of California that the information given above is true and correct and

that I am the person who was originally issued the Home Care Aide Registration. I hereby certify that this name and/or address

change is not made for fraudulent purposes.

*Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798 et seq.) notice is given for the

request of your Social Security Number (SSN) on this form. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of

this form. You have a right to access certain records containing your personal information maintained by the Department (Civil Code Section 1798 et

seq.). Under the California Public Records Act and the Freedom of Information Act, the Department may have to provide copies of some of the records

in the file to members of the public who ask for them, including newspaper and television reporters.

HCS 105 (12/15)