South Carolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 COURT CERTIFICATE , Plaintiff (s) vs. , Defendant(s) was filed in this Court under date of , , with affidavit of service showing service of the Summons upon the defendant(s). (SEAL) Clerk of Court Court DATED: County State WCC Form # S-4 Rev. 1986 S-4 Court Certificate American LegalNet, Inc. www.FormsWorkFlow.com