Form 99 Request For Duplicate/notice Of Change Template
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1Mail Completed Form to:
Please check ONE.
Michigan Department of State
Information Change (No Fee)
Office of the Great Seal
Duplicate Commission ($10 Fee)
7064 Crowner Drive
Lansing, MI 48918-1750
MICHIGAN DEPARTMENT OF STATE
OFFICE OF THE GREAT SEAL
Lansing, Michigan 48918-1750
Telephone: 517/373-2531
Michigan Notary Public: Request for Duplicate/Notice of Change
Original Information (Complete All Sections)
1.
Driver License or Personal Identification Card
Number:
State:
2.
Full Name:
(First)
(Middle)
(Last)
3.
Commissioned Name:
(First)
(Middle)
(Last)
4.
Date of Birth:
Month __ __ Day__ __ Year__ __ __ __
5.
Residence Address:
Number & Street
City
State
Zip
6.
E-mail Address: (Optional)
7.
Business Address:
Number & Street
City
State
Zip
8.
County:
County of residence.
9.
Commission
County of employment (if non-
Month __ __ Day__ __ Year__ __ __ __
Michigan resident).
Expiration Date:
(______)_____-_______
(______)_____-_______
10. Telephone Numbers:
(Residence)
(Business)
New Information (Complete Only Those Sections That Are Changing)
1.
Driver License or Personal Identification Card
Number:
State:
2.
Full Name:
(First)
(Middle)
(Last)
3.
Commissioned Name:
(First)
(Middle)
(Last)
4.
Date of Birth:
Month __ __ Day__ __ Year__ __ __ __
5.
Residence Address:
Number & Street
City
State
Zip
6.
E-mail Address: (Optional)
7.
Business Address:
Number & Street
City
State
Zip
County of residence.
8.
County:
9.
Commission
County of employment (if non-
Month __ __ Day__ __ Year__ __ __ __
Michigan resident).
Expiration Date:
(______)_____-_______
(______)_____-_______
10. Telephone Numbers:
(Residence)
(Business)
X
Please sign your name as it will appear on documents you notarize.
(Date)
By affixing my signature above, I understand that all information contained on this application form is
subject to disclosure under the Freedom of Information Act, 1976PA442, MCL 15.231 et seq. I am
enclosing a check or money order in the amount of $10, payable to The State of Michigan, which I
.
understand is a non-refundable processing fee
Form 99 (3/04)
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