Fillable Illinois Notary Public Remittance Agent Registration (Illinois Secretary of State)

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Illinois Notary Public Remittance Agent Registration (Illinois Secretary of State)

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Illinois Notary Public Remittance Agent Registration
(5 ILCS 312/2-107)
Secretary of State Index Department
111 E. Monroe
Springfield, IL 62756
217-782-7017
www.cyberdriveillinois.com
Company Name:_______________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
City, State, ZIP: _______________________________________________________________________________________________
Contact Person: _______________________________________________________________________________________________
Contact Person’s Phone: ________________________________________________________________________________________
Contact Person’s Email Address: __________________________________________________________________________________
CERTIFICATION
I certify that _________________________________________________________________________________,
Name of Entity
is a:
n
Corporation
n
Limited Liability Company
n
Partnership
n
Sole Proprietorship
n
Other
The entity engages in the business of, but not limited to, submitting applications and application fees on behalf of
applicants for notary public credentials on a regular and ongoing basis; issuing notary public surety bonds; providing
education services and qualifying exams; supplying notary public stamps/seals and supplies; and that (check all
below):
1.
n
Yes
n
No The applicant has not been the subject of any administrative citation, criminal complaint, or
civil complaint arising from his or her duties as a notary public remittance agent in the State of Illinois, If yes,
explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2.
n
Yes
n
No The remittance agent holds a surety bond in the amount of $20,000 affecting action by Illinois
applicants for notary public credentials in Illinois.
Printed by authority of the State of Illinois. December 2019 — 50 — I 241
Calender Year: _______________
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Reset
3.
n
Yes
n
No The remittance agent complies with all requirements set forth by the Secretary of State for the
submission of notary public applications.
Pursuant to 5 ILCS 312/2-107, if any question above is in the negative, the application will be reviewed by the Office of the
Secretary of State, Department of Index for a determination. In the event that the requested registration is denied, the applicant
shall be entitled to an administrative hearing with the Office of the Secretary of State, Department of Administrative Hearings.
Under penalties pursuant to Section 1-109 of the Code of Civil Procedures (*), the undersigned certifies that the statements set
forth in the above and foregoing registration are true and correct.
___________________________________________________ __________________________________________________
Signature of Agent for Notary Public Remitter Date
___________________________________________________ __________________________________________________
Name of Agent for Notary Public Remitter (Type or Print) Telephone Number at which Agent may be contacted
(*) Any person who intentionally makes a false, material statement on this Notary Public Remittance Agent Registration, shall be
guilty of a Class 3 Felony.
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Illinois Notary Public Remittance Agent Registration (Illinois Secretary of State)

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Completed 28 August 2020

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