Secretary of the State--Notary Public Unit PO Box 150470 Hartford CT 06115-0470 (860) 509-6100 Filing Fee $15.00 Notary Public Change of Address Form This form is for a change of address only. If you have a change of name, you will need to complete the change of name form. Instructions: Complete this form legibly in ink and send the signed original to the above address along with a nonrefundable statutory fee of $15.00. Make check payable to "Secretary of the State". Do not send cash. All questions (if applicable) must be answered completely before your request will be processed. Do you need a free copy of the Notary Public Manual revised July 2006? Yes No Date: ________________________ Daytime telephone number: _________________________ (Area code & number) Name of notary public: __________________________________________________________ (Name that appears on your current notary public certificate) Notary account number: __________________Date commission expires: __________________ Previous residence address: Current residence address (Must include street address. A PO box may be given only if mail delivery is not available to resident address. A business address will not be used). ___________________________________________ ______________________________________________ ___________________________________________ ______________________________________________ ___________________________________________ ______________________________________________ NON-RESIDENT NOTARIES must maintain and provide their principal place of business in the State of Connecticut for the term of their appointment (must include business name). This information is required by non-resident notaries. Previous business name & address: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Signature of Notary Public G: Forms/Notary Rev. 09/09 American LegalNet, Inc. www.FormsWorkFlow.com Current business name & address: __________________________________ __________________________________ __________________________________ __________________________________