Free OFFICE OF THE SECRETARY OF STATE - South Carolina

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For Office Use Only Check # ___________

STATE OF SOUTH CAROLINA OFFICE OF THE SECRETARY OF STATE
Notary Division Post Office Box 11350 Columbia, SC 29211

Fee Paid ___________

(803) 734-2512 (803) 734-1938

Request for Duplicate Notary Public Commission or Change of Name of Notary Public
The applicant is requesting the following:
(Please check the appropriate box or boxes. There is a $10.00 fee for each action requested.)

[ ] Duplicate Copy of Notary Public Commission - $10.00 [ ] Notary Public Name Change - $10.00

COUNTY OF _______________________ Name on original application __________________________________________________________________ IF requesting a name change, enter new name here _________________________________________________ Present Address_____________________________________________________________________________ City and Zip Code _________________________________ Social Security # __________________________ Date of Birth _________________________ EMAIL______________________________________________ Voter Registration # __________________________________

_______________________________________ Date _______________________________________ Signature of Applicant

Sworn to and subscribed before me this ________day of ______________________20_____

__________________________________________ Notary Public of South Carolina My Commission expires_______________________

MAIL REQUEST FORM AND CORRECT FEE TO THE ABOVE ADDRESS