STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Office of the Secretary of State Corporations Division Notary Public Section 148 W. River Street Providence, Rhode Island 02904-2615 (401) 222-1487 NOTARY PUBLIC CHANGE OF NAME FORM Instructions: Type or print the form legibly in ink. Return the signed original to the above address. Notary ID number: _____________________ Previous name of Notary Public: ______________________________________________________________________ (name that appears on your current notary public certificate) New name of Notary Public: __________________________________________________________________________ Date commission expires: ____________________________________ Name changed by reason of (check one) Marriage Divorce Petition to Change Name Address of Notary Public: ____________________________________________________________________________ (Must include street address. PO box may be given as additional information only.) _________________________________________________________________________________________________ (city/town) (zip code) Is this a change of address? (If so, please check box Daytime telephone number: _____________________________ (area code & number) You must complete the jurat in front of a notary. Jurat Date: ___________________ __________________________________________________________ Signature of Notary Public (new name) State of Rhode Island County of _____________________ Subscribed and sworn to before me at _________________ this ________day of ___________________, 20___. ___________________________________________________ Notary Public My Commission Expires: _______________________________ Form No. NF-3 Revised: 12/05 American LegalNet, Inc. www.USCourtForms.com