Department of the Secretary of State Bureau of Corporations, Elections and Commissions Notary Public Section 101 State House Station Augusta, ME 04333-0101 Request by Notary Public to Change Name and/or Address Expiration Date of your Notary Public Commission: _________________________________________________ Effective date of the change of name and/or address: _________________________________________________ Current name under which you are authorized to act as a Notary Public: ___________________________________________________________________________________________ New name under which you will be authorized to act as a Notary Public: ___________________________________________________________________________________________ Signature___________________________________________________ Current home mailing and physical address: (please provide complete address for both including zip code) _____________________________________________________________________________________ _____________________________________________________________________________________ (mailing address) _____________________________________________________________________________________ _____________________________________________________________________________________ (physical address, if different from above) E-mail address:_______________________________________ Other language fluency:_________________ Current town/city of residence: __________________________ Date of Birth: ________________________ Telephone numbers: Work: ______________________________ Home: _________________________ IF YOU WISH TO RECEIVE A NEW NOTARY PUBLIC CERTIFICATE OF OFFICE SHOWING THE ABOVE CHANGE, PLEASE INCLUDE A COPY OF YOUR CERTIFICATE WITH THIS FORM. If you are filing a change of name, please include a photocopy of the paperwork authorizing the change, such as a marriage certificate or divorce decree. Form No. Notary-2 Rev. 10/2004 American LegalNet, Inc. www.USCourtForms.com