DO NOT WRITE IN THIS SPACE State of Arizona Notice of Loss or Theft Notary Journal/Seal/Commission Certificate Mail to: Arizona Secretary of State Ken Bennett Attention: Business Services, Notary Department 1700 W. Washington Street, 7th Fl., Phoenix, AZ 85007-2888 (602) 542-6187 (800) 458-5842 (within Arizona) Website: www.azsos.gov Please Note: A notary commissioned in the State of Arizona has 10 days to notify our office under statute of a stolen seal, certificate, and/or journal. FOR OFFICE USE ONLY – REV. 06/15/10 NOTICE OF LOSS OR THEFT OF NOTARY JOURNAL/SEAL/COMMISSION CERTIFICATE Contact Authorities Contact your local law enforcement agency and file a lost/theft report (A.R.S. § 41-323(b)). About this form Use this form to report to the Secretary of State the loss or theft of a Notary Journal and/or Seal and/or Commission Certificate. Notification Requirements A notary public shall notify the office within 10 DAYS as specified under A.R.S. § 41-323(B). Failure to comply with this law may result in a $25 civil penalty fee. Under A.R.S. § 41-323(C), failure of notification may be grounds for a commission to be revoked because “the notary has failed to fully and faithfully discharge the duties of a notary.” Replacement Commission Certificate Fee: To request a new commission certificate, send this notice with a check or money order of $18 made payable to Secretary of State. Credit cards are not accepted. The certificate is mailed to the mailing address on file. How to complete this form Print clearly for accuracy or computer generate this form online. Fill in ALL blank fields. If a field is “not applicable” please designate your response by inserting n/a in the field provided. Report Submission Requirements This report must be sent by means providing a receipt under A.R.S. § 41-323(B). Send it by certified mail, fax it to (602) 542-4366 or deliver in person to the Secretary of State’s Phoenix Customer Service Center or Tucson office (see addresses below). Send completed notice by CERTIFIED MAIL to the address above, or return in person: PHOENIX - State Capitol TUCSON - Arizona State Executive Tower Complex Building 1700 W. Washington Street 400 W. Congress First Floor, Room 103 Second Floor, Room 252 Open Monday through Friday, 8 a.m. to 5 p.m. except state holidays. 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. NOTICE OF LOSS OR THEFT ~ CHECK APPROPRIATE BOXES a. JOURNAL MISSING STOLEN b. SEAL MISSING STOLEN DESCRIPTION OF OLD SEAL COLOR INK SHAPE DATE MISSING or STOLEN DATE MISSING or STOLEN OTHER It is recommended that you purchase a new seal that is a different shape from the missing seal to distinguish it from the old seal. DESCRIPTION OF NEW SEAL c. COLOR INK SHAPE COMMISION CERTIFICATE OTHER MISSING STOLEN DATE MISSING or STOLEN Please send me a replacement commission certificate. Enclosed is a check or money order for $18 made payable to the Secretary of State. 3. LOSS/THEFT ENFORCEMENT AGENCY REPORT INFORMATION REPORT OR CASE NUMBER DEPARTMENT, OFFICE or AGENCY NAME NAME of OFFICER OR AGENT PREPARING REPORT CONTACT INFORMATION (Phone, e-mail, address etc.) 4. NOTARY SIGNATURE ~ This notice shall be signed by the notary public under A.R.S. § 41-323(B) SIGNATURE (Required) Office Form SOSBSnotic e.doc PHONE NUMBER Notic e of Theft - Not ary, Journal/Seal/C ertifi cat e DATE American LegalNet, Inc. www.FormsWorkFlow.com