Home Tuition - Change of name form (HT6 SEN)

• Published date: 25 October 2019
• Issuer: Department of Education

Rannóg na nÍocaíochtaí Teasgasc Baile Home Tuition Payment Section,

Rannán na Scoileanna- Airgeadas, Schools Division – Financial,

An Roinn Oideachais agus Scileanna Department of Education and Skills

Cor na Madadh Cornamaddy

Baile Átha Luain Athlone

Co. na hIarmhí N37X659 Co. Westmeath N37X 659

_________________________________________________________________________________

 +353-9064-83600  +353-090648148  www.education.ie

 htpayments@education.gov.ie HT6 FORM – Sept. 2017

REQUEST TO CHANGE THE PERSONAL NAME ON THE RECORDS

HELD BY THE DEPARTMENT OF EDUCTION & SKILLS.

Important: This Department can only maintain one name for each individual.

Current details held by this Department.

Name: ____________________ PPSN: ______________

Date of Birth : _______________________ Teaching Council Registration Number : ____________

I, the undersigned, wish to inform the Department of Education & Skills, that I have now changed my

name from that which is listed above to :

________________________________________________________

With effect from: _____________________

I confirm that I wholly renounce, relinquish and abandon the use of my old name and in place thereof

assume and adopt from the date listed above my new name so that I may hereafter be called known and

distinguished not by my old name but by my new name.

That I shall at all time hereafter in all records , deeds and documents and any other writing and in all actions,

suits and proceedings as well as in all dealings, transactions matters and things whatsoever and upon all

occasions use and subscribe my new name in place and in lieu of my old name relinquish as aforesaid.

That I expressly authorise and request all persons at all times herafter to designate and address me by my

assumed and adopted new name.

That I have informed and notified the Revenue Commissioners and the Department of Employment Affairs

and Social Protection of my name change and I attach a copy of the notification received from them

confirming the name change,

Old Name Signature : _________________________________________ Date: ________________

New Name Signature : _________________________________________ Date : ________________

Reason for name change :

Marriage : __________________ Please forward your legal Marriage Certificate

Deed Poll : _________________ Please forward copy of your registered deed poll

Other Reason : ________________ Please forward any and all supporting documentation.