"Name or Address Change Request Form" - South Carolina

Name or Address Change Request Form is a legal document that was released by the South Carolina Department of Labor, Licensing and Regulation - a government authority operating within South Carolina.

Form Details:

  • The latest edition currently provided by the South Carolina Department of Labor, Licensing and Regulation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the South Carolina Department of Labor, Licensing and Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download "Name or Address Change Request Form" - South Carolina

Download PDF

Fill PDF online

Rate (4.6 / 5) 20 votes
Page background image
South Carolina Department of Labor, Licensing and Regulation
South Carolina Board of
110 Centerview Dr. • Columbia • SC • 29210
Long Term Health Care Administrators
P.O. Box 11329 • Columbia • SC 29211-1329
Phone: 803-896-4544 •
Contact.LTHCA@llr.sc.gov
• Fax: 803-896-4515
llr.sc.gov/lthc
NAME OR ADDRESS CHANGE REQUEST FORM
Submit the following with your application to the above address:
• Check or money order, in the amount of $25 made payable to Long Term Health Care
Administrators Board (Fees are non-refundable). A returned check fee of up to $30, or an
amount specified by law, may be assessed on all returned funds. NO CASH IS
ACCEPTED.
• Legal documentation of name change (i.e. marriage license, court order, or divorce decree)
License No.:
Name on License:
Name be change to:
Contact Update:
(if no change, please leave blank)
Mailing Address:
Street
City
State
Zip Code
Home Phone: _________________________________ Phone: ___________________________
Email Address: __________________________________________________________________
Signature:
Date:
Certificate Reprint
If you wish to receive a reissued certificate, complete the section below and mail in form with a check or
money order in the appropriate amount. A returned check fee of up to $30, or an amount specified by law,
may be assessed on all returned funds.
Quantity
Cost per document
Total
Reissued Certificate
$25.00
$ 0.00
Record Change Fee
$25.00
Total Amount Enclosed
*You can print a copy of the pocket card only at no charge by clicking on “Print copy of your
license” at http://www.llr.sc.gov/lthc.
South Carolina Department of Labor, Licensing and Regulation
South Carolina Board of
110 Centerview Dr. • Columbia • SC • 29210
Long Term Health Care Administrators
P.O. Box 11329 • Columbia • SC 29211-1329
Phone: 803-896-4544 •
Contact.LTHCA@llr.sc.gov
• Fax: 803-896-4515
llr.sc.gov/lthc
NAME OR ADDRESS CHANGE REQUEST FORM
Submit the following with your application to the above address:
• Check or money order, in the amount of $25 made payable to Long Term Health Care
Administrators Board (Fees are non-refundable). A returned check fee of up to $30, or an
amount specified by law, may be assessed on all returned funds. NO CASH IS
ACCEPTED.
• Legal documentation of name change (i.e. marriage license, court order, or divorce decree)
License No.:
Name on License:
Name be change to:
Contact Update:
(if no change, please leave blank)
Mailing Address:
Street
City
State
Zip Code
Home Phone: _________________________________ Phone: ___________________________
Email Address: __________________________________________________________________
Signature:
Date:
Certificate Reprint
If you wish to receive a reissued certificate, complete the section below and mail in form with a check or
money order in the appropriate amount. A returned check fee of up to $30, or an amount specified by law,
may be assessed on all returned funds.
Quantity
Cost per document
Total
Reissued Certificate
$25.00
$ 0.00
Record Change Fee
$25.00
Total Amount Enclosed
*You can print a copy of the pocket card only at no charge by clicking on “Print copy of your
license” at http://www.llr.sc.gov/lthc.