COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Approved by State Board of Accounts , 1997 TODD ROKITA : SECRETARY OF STATE : Sta te Form 40889 (R7 / 1-03) Index No. Calendar No. NOTARY PUBLIC APPLICATION* SUBPOENA : JUDICIAL Plaintiff(s) -against- : : Including: : Request to be appointed a Notary Public Notarial Oath Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . .Notarial. Bond . . . . . . . . . . . . . . . . ..... .... Instructions THE PEOPLE OF THE STATE OF NEW YORK TO IC 33-16-2-1: (as amended) GREETINGS: Sec. 1 (a) Any applicant for a commission as a notary public shall possess the following qualifications: (1) be at least eighteen (18) years of age; and (2) be a legal resident of the State of Indiana. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County ofo t ar y p u b l i c sh al l b e ap p o i n t ed a n d co m m is si o n ed b y t h e G o v er n o r. A n o t ar y p u bl i c s h al l h o l d (b) A n in room (8) years. ,A notary public, when so qualified, shall be,authorized to act within the State of Indiana. A person may on the day of , 20 at o'clock in the noon, and at any recessed office for eight or an application to become a notarygive evidence as a witness State. The applicationpart of the adjourned date, to testify and public from the Secretary of in this action on the shall be prescribed by the Secretary of request State and shall include the applicant's county of residence, oath of office, and official bond. The application shall also contain any additional information necessary for the efficient administration of this chapter. The applicant shall personally appear, with an application, before an officer authorized by law to administer oaths who shall administer an oath of office to the applicant. The Your failure to comply with this or corporate punishable as a contempt of court and State in the sum of five applicant shall secure an official bond, with freeholdsubpoena is security, to be approved by the Secretary ofwill make you liable to the party on whose behalf this subpoena was issued forupon the faithful performance and discharge of the duties of as a thousand dollars ($5,000). The official bond shall be conditioned a maximum penalty of $50 and all damages sustained the result of public, in all things according to law, for the use of any person injured by a breach of the condition. The completed office of notaryyour failure to comply. application shall be forwarded to the Secretary of State. The Secretary of State shall forward each commission issued by the Governor to the applicant or the applicant's surety company. Witness, Honorable , one of the Justices of the Court in County, day of , 20 Notary Department(Attorney must sign above and type name below) Secretary of State's Office Room 201 State House Indianapolis, Indiana 46204 317-232-6542 Attorney(s) for * T h i s ap p l i cat i o n sh o u l d al s o b e f i l l ed o u t b y cu r r en t n o t ari e s p u b l i c d esi r i n g t o ex t e n d t h ei r co m mi s si o n Office f o r an o t h er t er m . Th er e i s n o se p ara t e re n ew al fo r m o r p r o ced u r e. and P.O. Address IT IS A CRIME TO PERFORM ANY OF THE DUTIES OF A NOTARY PUBLIC U NTIL COMMISSIONED BY THE Telephone No.: GOVERNOR. IT IS IMPORTANT THAT YOU POSSESS A CURRENT, VALID COMMISSION BEFORE ACTING AS A Facsimile THE NOTARY PUBLIC. THE FILING OF THIS APPLICATION OR THE TAKING OF No.: OATH CONTAINED AS PART OF THIS APPLICATION DOES NOT AUTHORIZE YOU TO ACT AS A NOTARY PUBLIC. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. NOTARY APPLICATION INSTRUCTIONS : Calendar No. 1. Appl ication for Notary Public may be obtained fr om th e Secretary o f State, the C lerk of the C ircu it C ourt , or a : bonding company. Applications can be p hotocop ied if all parts of the applicatio n remain o n the front and back of JUDICIAL SUBPOENA Plaintiff(s) one piece of paper. 2. T h e a pp l i ca t i o n m u s t be -against- u t co m p l et e l y. T h e a p p l i:ca t i o n mu s t b e t y p e w ri t t e n o r p ri n t e d . fille d o D o no t l e a v e a n y b l a n k s . I f a n y i t em i s n o t a p p l i ca b l e t o y o u , p l e a se i n d i ca t e t h a t f a ct w i t h t h e w o rd s "n o t a p p l i c a b l e" o r " n o n e " o r "N A ". : In giving your name in item #1 on the application, you should print or type your name the way you will sign your name as a notary public. Your first or middle name may be initialed, but we suggest either your first full name or your second full name : or both, whichever you prefer. For example: John S. Smith, J. Samuel Smith, or John Samuel Smith; but not J. S. Smith. Your commission will be issued in the name given in item #1 and when performing a notarial act you should always sign your name the way it appears on your commission. Defendant(s) This requirement is for identification purposes and is for your protection. : 3. ...................................................... 4. If you are makin g reapplication, it is imp ortant for y ou to complete item #7 on the application and show yo ur expiration date so that when your new commission is issued there will be no lapse or overlap. (If your commission has recently expired, do not show your old expiration date in #7. Show an expiration date only if your commission is still in effect when you complete the application.) Reapplications should not be sent to the Secretary of State's office earlier than sixty (60) days THE PEOPLE OF THE before the expiration date. STATE OF NEW YORK 5. After the first seven items of the application have been filled out, take the application to an officer authorized by law to TO administ er oaths (e.g. another notary public, th e C lerk of the C ircuit Co urt, etc.). The oath of office (item #9 of t he appl ica tion) wil l b e admin istered to you by that o fficer. B e su re to read i nstruct ions #6, 7 , 8, 9 and 10 below. PLEASE NOTE: BEFORE TAKING THE OATH IT IS IMPORTANT TO DETERMINE IF YOU ARE QUALIFIED TO BE GREETINGS: A NOTARY PUBLIC. A. INDIANA LAW STATES THAT IT SHALL BE AN INDISPENSABLE QUALIFICATION FOR PERSONS TO HOLD ANY OFFICE WITHIN THE STATE OF INDIANA, EITHERand excuses being laid aside, you and each of you attend before WE COMMAND YOU, that all business BY ELECTION OR APPOINTMENT, THAT SUCH PERSONS SHALL NEVER the Honorable HAVE BEEN CONVICTED OF ANY CRIME AGAINST THE LAWS OF THE UNITED STATES WHERE at the Court THE SENTENCE IMPOSED EXCEEDED SIX (6) MONTHS (IC 5-8-3-1). located at County of B. NO PERSON HOLDING ANY LUCRATIVE OFFICE OR APPOINTMENT UNDER THE UNITED STATES OR UNDER in room on the , 20 , THIS STATE FROM HOLDING MORE THAN ONE o'clock in the noon, and at any recessed THIS STATE, AND ,PROHIBITED dayTHE CONSTITUTION OF at BY of or adjourned date, toOFFICE, SHALL evidence asA NOTARYin this action on theACCEPTANCE OF ANY SUCH SUCH LUCRATIVE testify and give SERVE AS a witness PUBLIC, AND HIS part of the OFFICE SHALL VACATE HIS APPOINTMENT AS SUCH NOTARY; BUT THIS PROVISION SHALL NOT APPLY TO ANY PERSON HOLDING ANY LUCRATIVE OFFICE OR APPOINTMENT UNDER ANY CIVIL OR SCHOOL CITY OR TOWN OF THIS STATE. (IC 33-16-2-7) C. EVERY PERSON ELECTED OR APPOINTED TO ANYis punishable as aTHIS CONSTITUTION SHALL, BEFORE Your failure to comply with this subpoena OFFICE UNDER contempt of court and will make you liable to ENTERING ON THE DUTIES THEREOF, TAKE AN OATH OR AFFIRMATION TO SUPPORT THE CONSTITUTION the party on whose behalfTHE UNITED STATES, AND for a maximum OF OFFICE. (Indiana Constitution, sustained as a OF THIS STATE, AND OF this subpoena was issued ALSO AN OATH penalty of $50 and all damages Article result of your failure to comply. 15, Section 4) 6. 7. 8. 9. 10. Witness, Honorable , one of the Justices app licant must An of ficial bo nd, with freehold o r corpo rate securit y, must be secu red i n the sum of $ 5,000. Theof the sig n in item #10 and hav e his signat ure acknowledged in ,#11. (Freeho ld security must be approved by the SecreCourt in County, day of 20 tary of State and item #13 of the application is only compl eted i n the case of a freeh old bond. A freeh old bond is when someon e o ther than th e appli can t, who own s land wort h at least $5,000, is the suret y.) Corpo rate secu rity can be obtain ed by taki ng the app lication t o a b onding compan y for co mp letio n. Insurance co mpanies and agents are often q ual ified to prov ide cor porate secu rity. Items #1 0, 11 and 12 of th e appli catio n mak e up the bon d. (Attorney must sign above and type name below) In the case of a corporate security, a power of attorney showing that the individual signing for the bonding company has aut hority to execute th e bond shoul d be at tached to th e app lication wh en it is su bmitted to the Secret ary of State. The completed application, including the oath of office and bond, should be forwarded to the Secret ary of State with Attorney(s) for a fee of five dollars ($5), payable to the Secretary of State, in the form of a check or money order. Do not send currency in the mail. Th e S ecr et ary o f St at e wi l l f o rw ar d y o u r co mm i ssi o n t o yo u (o r t o y o u r su r et y co m pan y, i f r eq u est ed t o d o so by en cl os i ng a s el f- ad dr es sed r et u r n en v el o pe w i t h t h e ap p l i cat io n . ) Please tear off and keep these instructions. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . Do .Not .Write .In This .Box .- .For Office.Use Only ......... .. .. .. ... .... .. ...... : Index No. Commission # _________________________________ Expiration Date of New Commission ___________________________________________ : Calendar No. APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA : Plaintiff(s) Complete and Return to: JUDICIAL SUBPOENA -against: Notary Department, Secretary of State, Room 201, State House Indianapolis, Indiana 46204: Telephone: 317-232-6542 : To: THE GOVERNOR OF INDIANA : I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond, oath of office, and fee of FIVE DOLLARS ($5), payable to the Secretary of State, in the form of a check or money order. (Do not send currency in Defendant(s) : the mail.) .(IC 33-16-2-1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... PRINT OR TYPE 1. NAME __________________________________________________________________________________________________________ 2. HOME ADDRESS __________________________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK which commiss ion will be issued - s ee instruction #3 Your legal signature in Number and s treet TO __________________________________________________________________________________________________________________ City State ZIP code 3. COUNTY OF RESIDENCE _______________________________________________________________________________________ 4. Business or Employer's Name _____________________________________________________________________________________ 5. Business or Employer's Address ___________________________________________________________________________________ 6. 7. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Street City Court State ZIP code , the Honorable at the ( ) ( ) located at County of HOME PHONE _______________________________________ OFFICE P HONE ________________________________________ Area Code Number Area Code Number in room , on the day of , 20 , at o'clock in the noon, and at any recessed If you have a current valid notary commission, show your expiration date: or adjourned date, to testify and give evidence as a witness in this action on the part of the __________________________________, 20 _______ 8. If you are now a notary public and your name or county has changed since your last application, please give both old and new information. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a OLD: ___________________________________________________________________________________________________________ result of your failure to comply. NEW: __________________________________________________________________________________________________________ 9. Witness, Honorable NOTARIAL OATH Court in County, day of ) STATE OF INDIANA SS: COUNTY OF _______________________________ ) , one of the Justices of the , 20 County in which oath is administered I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of thetype name below) that I am duly (Attorney must sign above and State of Indiana; qualified to hold office under the Constitution and laws of the State; that I am 18 years of age or over; that I am of good moral character and integrity; that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have carefully read all of the instructions which came with this application, and that I will faithfully and impartially discharge the duties of NOTARY PUBLIC if so commissioned by the Governor, according to the best of my skill and ability, so help me God (or under the pains and penalties of Attorney(s) for perjury). Signature of applicant Place Of fice r's Se al He re Subscribed and sworn or affirmed to before me, this Office and ________________________________________ _____ day of P.O. Address A.D. 20 _____. IN TESTIMONY WHEREOF, I, _____________________________________________________ Printed o r typed name of o fficer ______________________________________________, a ________________________________________ for the Telephone No.: Signature of a notary public or other officer authorized to administer oaths Office County of ___________________________________________, No.: of Indiana. Facsimile State Officer's coun ty of residen ce My commission expires: _________________________________________________ E-Mail Address: NOTE: Mobile Tel. No.: The Bond Form, starting with #10 on the back of this application, must be completed before mailing to the S ecretary of State. The applicant must sign again in #10. American LegalNet, Inc. www.USCourtForms.com 10. NOTARIAL BOND COURT KNOW ALL BY THESE PRESENTS, that we _________________________________________________________________________ as principal COUNTY OF ...................................................... Name of Applicant : (applicant) and _________________________________________________________________________________________________________ of Index No. Name of Surety __________________________________________________________________________ and _________________________________ County as : Street address, city, s tate & ZIP code Calendar No. freehold or corporate surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), the payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents. : JUDICIAL SUBPOENA Plaintiff(s) WITN ESS our signatures as ac knowl edged below. THE CO NDITIO N OF THE ABO VE O BLIG ATION IS AS F OLL OWS , TO-WIT. -against: W H ER EA S , t he a bo ve bo und pr in c ip al h as ap pl ie d fo r a pp oi nt me nt b y th e G ove r nor o f t he S t a te o f I ndi a na a s a N ot a ry P ub li c , i n an d f or t he S t at e of In di an a, f or a ei gh t- ye ar t er m . : Now, if the said principal shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective : date of the principal's commission to the expiration date of the same. Defendant(s) : . . . . . . .Signature of applicant.. Must.be.acknowledged . . . in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . below . #11 Signature of surety. Must be acknowledged below in #12 11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. STATE OF ________________________________________, COUNTY OF __________________________________________________: SS: THE PEOPLE OF THE STATE OF NEW YORK County in which acknowledgement is being made Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared TO ______________________________________________________________ and acknowledged the execution of the foregoing bond for the uses and Printed or typed name of applicant purposes therein expressed, without condition or reservation. IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my Place Of fice r's seal here Printed or typed name of officer GREETINGS: hand and official seal, this ___________ day of ________________________________, 20 _______. ___________________________________________________________, a __________________________________ Signature of authorized officer WE COMMAND YOU, that all business and excuses being laid aside, you and each ofoffice attend before you for the County of _____________________________________,Courtof ___________________________________. , State the Honorable at the idence Officer's county of res located at County of My commission expires: ______________________________________________________. in room , on the day of , 20 , at o'clock in the noon, and at any recessed 12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER or adjourned date, to TO TAKE give evidence as a witness in this The officer can not of the AUTHORIZED BY LAW testify andACKNOWLEDGEMENTS. (NOTE: action on the part acknowledge his/her own signature) STATE OF ____________________________________________, COUNTY OF _____________________________________________ : SS: County in which acknowledgement is being made Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to ______________________________________________________________ a maximum penalty of $50 of the all damages sustained as a the party on whose behalf this subpoena was issued for and acknowledged the execution and foregoing bond for the uses and Printed or typed name of individual s igning as surety result of your failure to comply. purposes therein expressed, without condition or reservation. Place Of fice r's seal here IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my Printed or typed name, one of the Justices of the of officer Witness, Honorable hand County, seal, this ___________ day of 20 and official ________________________________, 20 _______. Court in day of , ___________________________________________________________, a __________________________________ Signature of authorized officer office for the County of _____________________________________, State of ___________________________________. Officer's county of res idence (Attorney must sign above and type name below) My commission expires: ______________________________________________________. 13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY. STATE OF INDIANA, COUNTY OF _____________________________________________ : SS: County in which acknowledgement is being made Attorney(s) for The undersigned s urety, being duly s worn or affirmed, s ays that he/she is the owner in fee-simple of Real Estate in _______________________________________ County, of the fair Cash Value of $ _______________________________ over and above all encumbrances and exemptions. Place Of fice r's seal here Signature of surety Office and P.O. Address IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my Printed or typed name of officer hand and official seal, this ___________ day of ________________________________, 20 _______. ___________________________________________________________, a __________________________________ Telephone No.: Signature of authorized officer office Facsimile No.: for the County of _____________________________________, State of ___________________________________. Officer's county of res idence E-Mail Address: My commission expires: ______________________________________________________. Mobile Tel. statutes pertaining to Officer's Bonds and For the statute pertaining to surety company bonds, s ee Indiana Code 27-1-22. For theNo.: O aths , see Indiana Code 5-4. American LegalNet, Inc. www.USCourtForms.com