State of Wisconsin - Department of Financial Institutions OFFICE USE ONLY Rec'd Date: Notary ID: WISCONSIN NOTARY PUBLIC COMMISSION Change of Address/Name/Seal Most Recent Commission Date SEAL: First Name Legal First Name Email SEAL: Middle Legal Middle Name Current Notary Commission and Contact Information SEAL: Last Name Legal Last Name Birthdate Phone SEAL: Suffix Legal Suffix Effective Date of Change In Care of: (Business Name, if applicable) City Current/Updated Address Information State Street Address or PO Box Zip Code Name AND Seal Change ** SEAL: First Name Legal First Name SEAL: Middle Legal Middle Name Seal Addition/Change ONLY** SEAL: Last Name Legal Last Name Effective Date of Change SEAL: Suffix Legal Suffix Notary Signature (Must match stamped/imprinted seal exactly) Updated Seal Imprint or Stamp Updated Seal Imprint or Stamp This document can be made available in alternate formats, upon request, to qualifying individuals with disabilities. ** You may not use your new stamp/seal until you have received confirmation from the Wisconsin Department of Financial Institutions. Mail to: Notary Records Section Department of Financial Institutions PO Box 7847 Madison, WI 53707-7847 DFI/NOT104(R02/14) or Email readable copy to: DFINotary@wi.gov (Scanned document may be saved and attached to email.) or Fax readable copy to: (608) 264-7965 Questions: (608) 266-8915 TTY: 711 American LegalNet, Inc. www.FormsWorkFlow.com