Request To Change Record

Revised 10/11/2012 NEBRASKA SECRETARY OF STATE Business Services Division: Notary P. O. Box 95104 * Lincoln, NE 68509 www.sos.ne.gov Notary Public Request to Change Record Please type or print legibly in black ink Please return the form with the applicable fee to the address listed above. $30.00 fee for Name Change and no fee for address change. Please print: Name as it appears on your commission: Date commission issued : Mark all boxes that apply: I would like to change my name on my notary public commission. I would like to change my mailing address, email or phone on file to the information below. Complete the following for change of address : New Home Address Street Address Apartment/Unit # PO Box (if any) City State Zip Home Phone E - mail Address (optional) New Business Address ( Required for non - resident applicant, optional for resident applicant ) Non - resident Notaries Public must submit the Evidence of Employment form if the work address is being changed. Company Name Street Address City State Zip Work Phone Extension Complete the following for change of name: A bond under the new name must accompany this change form and a copy of the marriage certificate or court order . Applicant Information Last Name First M.I. Date of name change : Changed by : Marriage Court Order NOTARIAL OATH Your signature below will be used to verify your signature on other documents. You must sign consistently. State of County of I, , do solemnly (swear), (affirm) under penalty of perjury, that the answers to all questions on this application are true and complete to the best of my knowledge. X Subscribed and (sworn) (affirmed) before me : this day of , 20 . (Month) (Year) ^Affix Official Notary Seal^ Signature of Notary Public American LegalNet, Inc. www.FormsWorkFlow.com