Free 28801.pdf - Indiana

APPLICATION FOR REVISED OR DUPLICATE NOTARY COMMISSION
To be used in the case of name change, change of county or when original commission is misplaced.
State Form 28801 (R3 / 6-96) Approved by State Board of Accounts, 1989

Please Print or Type INSTRUCTIONS: Complete this form when appropriate and send with $5.00 payable to Secretary of State in the form of a check or money order (do not send currency in the mail). Mail to Secretary of State, Notary Department, Room 201, State House, Indianapolis, Indiana 46204.
Original commission number Date of expiration (month and day)

, 19
Name in which present commission was issued

Name in which revised commission is to be issued

County of residence of present commission

County of residence to be on revised commission

New residence address (street)

City

ZIP code

New home telephone number

Signature (sign name as it will appear on revised or duplicate commission)

New business telephone number

STATE OF INDIANA COUNTY OF
County in which acknowledgement is being executed

}
Name of person

SS:

Before me the undersigned, an officer authorized to take acknowledgements (Notary Public, Clerk of the Circuit Court, etc.) personally appeared __________________________________________________________ and acknowledged the execution of this instrument this _______ day of _____________________________________, 19 _______. IN TESTIMONY WHEREOF, I ________________________________________________, have hereunto set my hand and official
Printed or typed name of officer

seal, this _______ day of ______________________________________, 19 _______. ______________________________________________________, a _________________________________________________ for
Signature of Notary Public or other authorized officer Type of office

the County of ______________________________________.
Officer's county of residence

My commission expires ______________________________________, 19 _______.