Secretary of the State Attn: Notary Public Division PO Box 150470 Hartford, CT 06115-0470 Filing Fee $15.00 Notary Public Change of Name Form This form will also update a change of address in connection with this name change. DO NOT COMPLETE A SEPARATE FORM FOR AN ADDRESS CHANGE. 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? Date: ____________________________ Yes No Daytime telephone number: __________________________________ (Area code & number) Previous name of notary public: ___________________________________________________________________ (Name that appears on your current notary public certificate) New name of notary public: ______________________________________________________________________ Notary account number: ________________________ Name change by reason of (check one): Is this a change of address? (check box): Marriage Yes No Date commission expires: _________________________ Divorce Petition to change name 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. Previous residence address: __________________________________________ __________________________________________ __________________________________________ Current residence address: __________________________________________ _________________________________________ _________________________________________ Non-resident notaries must maintain and provide their principal place of business in the State of Connecticut for the term of their appointment. Current principal business address: (Must include business name). This information is required by non-resident notaries. Previous business name & address: ___________________________________________ ___________________________________________ ___________________________________________ Current business name & address: ________________________________________ _______________________________________ _______________________________________ NOTE: Before submitting this form, please have your signature notarized in front of a notary public, or other person empowered by law to administer oaths. __________________________________________________________ Signature of Notary Public (new name) G: Forms/Notary Rev. 09/09 American LegalNet, Inc. www.FormsWorkFlow.com