Notary Public Request To Change Record

Name as it appears on your commission Additional name(s) commissioned under Date commission issued County Date of Birth Email (Optional) Phone Number Mark all boxes that apply: Change Seal : I would like to use the new notary seal imprint shown . I intend to use both the new seal and my current notary seal. When I renew my commission, I am aware I will need to place an imprint of both notary seals on the application. I would like to discontinue the use of my current notary seal on file and use the imprint of the new notary seal shown . Change Name : I would like to change my name on my notary public commission and will use the imprint of the new notary seal above . Complete the following: Date of name change Changed by Court Order Marriage New name (as it appears on new notary seal) Change Address : I would like to change my physical address on file to the address below. Physical Address City State Zip County I would like to change my mailing address on file to the address below. Mailing Address City State Zip County I hereby state that the above information is true and correct. I understand that I will not be able to use a new notary seal imprint until I am notified by the Secretary of State. Dated (Signature EXACTLY as found on your seal imprint ) Notary Public Request to Change Record Please Type or Print Clearly in Ink No Filing Fee Return to: Secretary of State, 500 East Capitol Ave, Pierre, SD 57501 Make Imprint of New Seal Here FOR INTERNAL OFFICE USE ONLY File Date: Commission Date: Notary ID: American LegalNet, Inc. www.FormsWorkFlow.com