OFFICE OF THE SECRETARY OF STATE

ALABAMA CIVIL‑LAW NOTARY SIGNATURE AND SEAL

Form ACLN‑4

Effective xxxxxx xx, xxxx

Nature of Change:     □ Seal        □ Signature      □ Both

Name: _______________________________________________________________________

1. (Last)                              (First)                     (Middle)

   Date of Appointment: ____/____/____

   New Name: __________________________________________________________________

2. (Last)                           (First)                    (Middle)

   Residence Address:    ________________________________________________

   (Street)

   ________________________________________________

3. (City)                      (State)        (Zip Code)

   Business Address:     ________________________________________________

   (Street)

   ________________________________________________

4. (City)                      (State)        (Zip Code)

   Home Phone: (   )_____________       Business Phone: (   )_____________

   Alabama Driver’s License:_____________   Alabama Bar ID Number:_______________

   (Affix seal in this space,

   if filing a change.)

   If you are changing your seal pursuant to Rule 820‑6‑3‑.01(4), please affix to this form a copy of that seal

   Pursuant to Rule 820‑6‑3‑.01(4), please attach to this form a $50.00 processing fee payable to the Alabama Secretary of State.

   I hereby certify that the information indicated on this form is true and accurate and that the affixed seal is a graphic symbol unique to me. I understand any false statements herein constitute a violation of §13A‑10‑102, Code of Alabama (1975). I further certify that I am an Alabama Civil‑law Notary appointed by the Secretary of State and that I am filing this Form ACLN‑3 pursuant to Rule 820‑6‑3‑.01(4).

   (New Legal Signature of the Alabama Civil‑law Notary Filing this Form

   (Print or Type Legal Name)                                                     (Date)

   Office of Secretary of State · P.O. Box 5616 · Montgomery, Alabama 36103‑5616

Author: Charles E. Grainger, Jr., Jean Brown

Statutory Authority: Code of Ala. 1975, §§36-20-50, et seq.

History: New Rule (Forms): Filed January 10, 2001; effective February 14, 2001. Amended: Filed June 5, 2009; effective July 10, 2009.