Name as it appears on your commission Additional name(s) commissioned under Date commission issued County Date of Birth Email (Optional) Phone Number Mark all boxes that apply: Change Seal : I would like to use the new notary seal imprint shown . I intend to use both the new seal and my current notary seal. When I renew my commission, I am aware I will need to place an imprint of both notary seals on the application. I would like to discontinue the use of my current notary seal on file and use the imprint of the new notary seal shown . Change Name : I would like to change my name on my notary public commission and will use the imprint of the new notary seal above . Complete the following: Date of name change Changed by Court Order Marriage New name (as it appears on new notary seal) Change Address : I would like to change my physical address on file to the address below. Physical Address City State Zip County I would like to change my mailing address on file to the address below. Mailing Address City State Zip County I hereby state that the above information is true and correct. I understand that I will not be able to use a new notary seal imprint until I am notified by the Secretary of State. Dated (Signature EXACTLY as found on your seal imprint ) Notary Public Request to Change Record Please Type or Print Clearly in Ink No Filing Fee Return to: Secretary of State, 500 East Capitol Ave, Pierre, SD 57501 Make Imprint of New Seal Here FOR INTERNAL OFFICE USE ONLY File Date: Commission Date: Notary ID: American LegalNet, Inc. www.FormsWorkFlow.com