2016 Version CON_form~1.docx
DOCX document 97 KB Posted
- Solicitation number
- BD-15-1067-MCD01-MCD01-00000003934
- Issued by
- Suffolk County, Massachusetts
About this file
The document is a 2016 version of a change of name form for the Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH) Department of Interpreter and CART Services. The form allows current vendors to officially change their name with the agency, requiring submission of legal documentation such as a marriage license or court order. The vendor must wait for confirmation from MCDHH before using the new name on any invoices or other paperwork submitted to state agencies.
This form is related to the MCDHH01 Interpreter Contract Renewal for the FY'16 to FY'18 period. This contract is for interpreters and transliterators providing services to the deaf and hard of hearing in the Commonwealth of Massachusetts. The contract renewal process requires vendors to complete and submit this change of name form if applicable.
View the file
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Text version
The Commonwealth of Massachusetts Executive Office of Health and Human Services Massachusetts Commission for the Deaf and Hard of Hearing 600 Washington Street Boston, Massachusetts 02111 Tel. (617) 740-1600
TTY (617) 740-1700
VP (617) 326-7546
Fax (617) 740-1880 www.mass.gov/mcdhh
Department of Interpreter and CART Services / A & F Change of Name
To: MCDHH Business Department;
From: __________________________________________ Effective date of name change: ____________________
Please change my name from:
PREVIOUS NAME
Name:
To:
NEW NAME
New Name:
Type of Legal Document (court paper, divorce, marriage, etc:
email:
| Home Phone: |
| Work Phone: |
Signature of Vendor Date
Please wait for the letter confirming your name change has been processed and approved before submitting PVs and invoices using your new name to any state agencies.
Please attach a copy or marriage license or court document verifying name change and a copy of your new Social Security card reflecting your name change.
INTERNAL USE ONLY
MMARS updated – By: ______________________
Date sent to OSC: ____________________________
Approved by OSC – date: ____________________
Avianco updated – By: ______________________
Letter sent to Interpreter: ____________________
DATE RECEIVED
Effective 4/6/12 image1.wmf oleObject1.bin
File details come from the government source that posted it. Updated .