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. Approved by State Board of Accounts, 1989 State Form 28801 (R3 / 6-96) 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) STATE OF INDIANA New business telephone number } COUNTY OF SS: County in which acknowledgement is being executed 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 Name of person this _______ day of _____________________________________, 19 _______. IN TESTIMONY WHEREOF, I ________________________________________________, have hereunto set my hand and official seal, Printed or typed name of officer 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 _______. 2001 © American LegalNet, Inc.