NOTARY PUBLIC COMMISSION - CHANGE OF NAME To effect a change of name for notary purposes, purchase a new seal or rubber stamp. (See telephone book for supplies.) The seal or stamp must state the new name with the words "State of Wisconsin" and "Notary Public". No other words are permitted on an official notary seal or stamp. Then complete and return this Change of Name form to the Department of Financial Institutions prior to using the new name and seal for notary purposes. No certificate will be issued; however, a date-stamped photocopy of this form will be returned as a receipt. Mailing address: Department of Financial Institutions/Notary Records P.O. Box 7847, Madison, WI 53707 Office location: 345 W Washington Ave 3rd FL, Madison, WI (608) 266-8915 1) The commission was issued to: 2) Birthdate: 3) Notary commission expiration date: If permanent commission, date of issue: 4) New name (print): 5) Effective date* for name change for notary purposes: * Show a future date - do not complete by indicating "as soon as possible" or "immediately", or by showing a back date. This form must be filed prior to using a new name and seal. 6) Daytime telephone: 7) Current mailing address: 8) Sign new name twice, exactly as indicated on the new seal or stamp: 9) Practice affixing the new seal/stamp on another paper first, then affix two CLEAR impressions below: American LegalNet, Inc. www.FormsWorkFlow.com