State of Arizona ­ Office of the Secretary of State DO NOT WRITE IN THIS SPACE Notary Public Address/Name Change Form SEND BY MAIL TO: Secretary of State Ken Bennett, Atten: Notary Division 1700 W. Washington Street, FL. 7, Phoenix, AZ 85007-2808 KEN BENNETT Secretary of State OR return the application in person: TUCSON - Arizona State Complex, PHOENIX - State Capitol Executive Tower, 1700 W. Washington Street, 1st Fl., Room 103 400 W. Congress, 1st Fl., Suite 139-1 Office Hours: Monday through Friday, 8 a.m. to 5 p.m., except state holidays. FOR OFFICE USE ONLY SOSBSADDRESSNAME REV. 12/20/2013 PLEASE NOTE: This form must be submitted by certified mail or other means providing a receipt A.R.S. § 41-323(A). Submit your completed form by fax (602) 542-4366; certified mail; or in person. INSTRUCTIONS About this form: Complete this form to notify the Secretary of State of an address or name change to a Arizona Notary Public Commission. Address change: File an address change within 30 days of the change (A.R.S. § 41-323). Failure to notify of an address change within 30 days may result in a $25 civil penalty. Name change: File a name change within 30 days of the change of surname (A.R.S. § 41-327). Failure to notify the secretary of state of this change of surname is evidence of the notary's failure to fully and faithfully discharge the duties of a notary. The commission may be revoked. 1. Notary Information NOTARY COMMISSION NUMBER OR SOCIAL SECURITY NUMBER LAST NAME (As shown on notary certificate) FIRST NAME (As shown on notary certificate) MIDDLE (If used) 2. Address Change ~ Check appropriate box/boxes and update information a. NEW MAILING ADDRESS FORMER MAILING ADDRESS NEW MAILING ADDRESS DATE OF NEW MAILING ADDRESS CITY CITY DATE OF NEW HOME ADDRESS CITY CITY DATE OF NEW BUSINESS ADDRESS FORMER PHONE NUMBER FORMER PHONE NUMBER FORMER PHONE NUMBER NEW PHONE NUMBER ( ) ( STATE STATE ) ZIP CODE ZIP CODE b. NEW RESIDENTIAL ADDRESS FORMER HOME (Physical) ADDRESS NEW HOME (Physical) ADDRESS NEW PHONE NUMBER ( ) ( STATE STATE ) ZIP CODE ZIP CODE c. NEW BUSINESS ADDRESS FORMER BUSINESS NAME NEW PHONE NUMBER ( ) ( ) The Business Name and Address provided in the fields below are a public and will be displayed on our website. NEW BUSINESS NAME CITY CITY STATE STATE ZIP CODE ZIP CODE FORMER BUSINESS ADDRESS (This address is a public record) NEW BUSINESS ADDRESS (This address is a public record) 3. Name Change ~ Check appropriate boxes, fill in surname, attach name change documentation. NAME CHANGE & NOTARY COMMISSION: If you ONLY want to use your new name as a notary public you must apply for a new commission. Refer to the application for Notary Public Commission and instruction form for applicable requirements and fees. A.R.S. § 41-327: A notary public who has a change of surname may continue to use the official seal and commission in the notary public's prior name until that commission expires. The notary shall sign the changed surname on the line that is designated for the notary public's signature on the notarial certificate. Immediately below that signature, the notary public shall sign the name under which the notary was commissioned. NEW SURNAME IF OTHER, SPECIFY REASON FOR NAME CHANGE Marriage Divorce Other 4. Notary Signature SIGNATURE (Required) DATE Office Form SOSBSaddressname Notice of Address/Name Change American LegalNet, Inc. www.FormsWorkFlow.com