ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

CONFIDENTIAL

FOR COURT USE ONLY

NC-410

FAX NO. (Optional):

TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

      ATTORNEY FOR (Name):

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:

PETITION OF (Name of each petitioner):

APPLICATION TO FILE DOCUMENTS UNDER SEAL  
IN NAME CHANGE PROCEEDING UNDER 
ADDRESS CONFIDENTIALITY PROGRAM (SAFE AT HOME)

CASE NUMBER:

Before you complete this petition, you should read the Information Sheet for Name Change Proceedings Under 
Address Confidentiality Program (Safe at Home) (form NC-400-INFO). You must file a Declaration in Support of 
Application to File Documents Under Seal in Name Change Proceeding Under Address Confidentiality Program 
(Safe at Home) (form NC-420) with this application. You must file this application and the petition in the 
superior court of the county where the person whose name is to be changed resides.

1. 

Petitioner (name):
Secretary of State's address confidentiality program under Government Code sections 6205–6211 and is alleging one of the 
following as a reason for the name change: (1) seeking to avoid domestic violence, (2) seeking to avoid stalking, or (3) is, or is 
filing on behalf of, a victim of sexual assault.

is a participant in the

2.

Petitioner requests that the court file the following documents under seal:

Petition for Change of Name (form NC-100)

Attachment to Petition for Change of Name (form NC-110)

Order to Show Cause for Change of Name (form NC-120)

Decree Changing Name (form NC-130)

Civil Case Cover Sheet (form CM-010)

Application to File Documents Under Seal in Name Change Proceeding Under Address Confidentiality Program 
(Safe at Home) (form NC-410)

Declaration in Support of Application to File Documents Under Seal in Name Change Proceeding Under Address 
Confidentiality Program (Safe at Home) (form NC-420)

Order on Application to File Documents Under Seal in Name Change Proceeding Under Address Confidentiality 
Program (Safe at Home) (form NC-425)

Other

(specify):

The facts that support this petition to file the documents checked above under seal are stated in the Declaration in Support of 
Application to File Documents Under Seal In Name Change Proceeding Under Address Confidentiality Program (Safe at Home) 
(form NC-420).

Petitioner has completed each of the documents checked above, placed them in a sealed envelope, and is lodging the envelope 
with the court along with this application.

a.

b.

c.

d.

e.

f.

g.

h.

i.

3. 

4. 

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY OR PETITIONER WITHOUT ATTORNEY)

Form Adopted for Mandatory Use 
Judicial Council of California  
NC-410 [New January 1, 2010]

APPLICATION TO FILE DOCUMENTS UNDER SEAL 
IN NAME CHANGE PROCEEDING UNDER 
ADDRESS CONFIDENTIALITY PROGRAM (SAFE AT HOME)

Page 1 of 1
Code of Civil Procedure, § 1277; 
California Rules of Court, rule 2.577 
 www.courtinfo.ca.gov