Notary Public Request To Change Record Form - Business Services Division: Notary

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NEBRASKA SECRETARY OF STATE

Business Services Division: Notary

1445 K St., 1301 State Capitol Bldg.

P. O. Box 95104 * Lincoln, NE 68509

Notary Public Request to Change Record

Please type or print legibly in black ink

Please return the form with the applicable fee to the address listed above.

$30.00 fee for Name Change and no fee for address change.

Please print:

Name as it appears on your commission:

Date commission issued:

Mark all boxes that apply:

I would like to change my name on my notary public commission.

I would like to change my mailing address, email or phone on file to the information below.

Complete the following for change of address:

New Home Address

Street Address

Apartment/Unit #

PO Box (if any)

City

State

Zip

Home Phone

E-mail Address (optional)

New Business Address (Required for non-resident applicant, optional for resident applicant)

Non-resident Notaries Public must submit the Evidence of Employment form if the work address is being changed.

Company Name

Street

Address

City

State

Zip

Work Phone

Extension

Complete the following for change of name:

A bond under the new name must accompany this change form and a copy of the marriage certificate or court order.

Applicant Information

Last Name

First

M.I.

Date of name change:

Changed by:

Marriage

Court Order

NOTARIAL OATH

Your signature below will be used to verify your signature on other documents. You must sign consistently.

State of ____________________ County of ___________________

I, _____________________________________, do solemnly (swear), (affirm) under penalty of perjury, that the answers to all questions on this application are true

and complete to the best of my knowledge.

X_____________________________________________________

Applicant’s Signature

Subscribed and (sworn) (affirmed) before me : this _______ day of _______________, 20 ______.

(Month)

(Year)

________________________________________________

Affix Official Notary Seal^

Signature of Notary Public

Revised 10/11/2012