Notary Public Change of Address Notification John A. Gale Secretary of State State of Nebraska Notification of Address Change is required to be filed with the Secretary of State’s Office no later than 45 days after such change. Please print the following information as it appears in our official Notary records: Name :________________________________________________ Address:__________________________________ (exactly as it appears on your Notary Commission certificate) _________________________________________________________ (Address on most recent application or renewal on file in our office) Commission Expiration Date : ______________________ 1) NEW Notary Home (street) address and telephone : Address:___________________________________________________________________ Street address (may include PO Box only as secondary address) Telephone: ( City State Zip )_________________________ 2) Business Name and (street) address and telephone: (optional) Address : __________________________________________________________________ Street address (may include PO Box only as secondary address) Telephone : ( 3) City State Zip )_________________________ Address Designation: Check the box to indicate which of the addresses above is the address you wish to designate for mailing purposes. ? Home ? Business (if provided) I understand that I must be a resident of the State of Nebraska to qualify as a Nebraska Notary. Date: _______________ ______________________________________ Signature of Notary (as commissioned) Return this form to: Secretary of State’s Office Business Services Division (Notary) 1445 “K” St., Room 1301 State Capitol, PO Box 95104 Lincoln, NE 68509 SOS Notary July, 2004 American LegalNet, Inc. www.USCourtForms.com