Fillable Notary Public Change Of Address printable pdf download

Commonwealth of Pennsylvania – Department of State

Bureau of Commissions, Elections and Legislation

NOTARY PUBLIC

Division of Legislation and Notaries

CHANGE OF ADDRESS

210 North Office Building

(Revised 9/30/2011)

Harrisburg, PA 17120

Tel: (717) 787-5280 Web:

Section 7. Vacation of office; change of residence (57 P.S. § 153)

(a) In the event of any change of address within the Commonwealth, notice in writing or electronically

shall be given to the Secretary of the Commonwealth and the recorder of deeds of the county of original

appointment by a notary public within five (5) days of such change. For the purpose of this subsection,

"address" means office address.

PRINT OR TYPE CLEARLY. FILL OUT FORM COMPLETELY. Do not leave any blanks.

Use “none” or “N/A” if applicable. There is no fee for filing this form with the Department of

State. Please check with the applicable Recorder of Deeds office whether this form may be

used and for any recording fee.

Notary commission expiration date

Notary commission ID number

For Official Use Only

Full name as commissioned

Date of Birth (mm/dd/yyyy)

Email address where you can be contacted about

this form: _______________________________

Employer/Business Information of Record

Old Employer/Business Name

Employer/Business Street Address (P.O. Box alone is insufficient)

City

State

Zip Code

Employer/Business Telephone (include area code)

Municipality (city/borough/township)

County

New Employer/Business Information of Record (NOTE: Employer/Business contact information will be public record)

New Employer/Business Name

Employer/Business Street Address (P.O. Box alone is insufficient)

City

State

Zip Code

Employer/Business Telephone (include area code)

Municipality (city/borough/township)

County

Home Address of Record

Home Street Address (P.O. Box alone is insufficient)

City

State

Zip Code

Home Telephone (include area code)

Municipality (city/borough/township)

County

New Home Address of Record

Home Street Address (P.O. Box alone is insufficient)

City

State

Zip Code

Home Telephone (include area code)

Municipality (city/borough/township)

County

APPLICANT AFFIDAVIT: I shall furnish additional evidence of these statements, if requested, which shall be satisfactory to the Secretary of the Commonwealth. To the best of my knowledge

and belief, this filing contains no misrepresentations or falsifications, omission or concealments of material fact and the information given by me is true and complete. I understand that any

false statement made is subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities) and may result in the suspension, revocation, or denial of my notary

commission.

_____________________________________________________________________________

________________________________________________

Notary Signature (must match full name as commissioned)

Date