Application For Appointment As A Notary Public In The State Of Indiana Form - Secretary Of State, State Of Indiana Page 2
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210. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we _________________________________________________________________________ as principal
Name of Applicant
(applicant) and _________________________________________________________________________________________________________ of
Name of Surety
__________________________________________________________________________ and _________________________________ County as
Street address, city, state & ZIP code
freehold or corporate surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), the
payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents.
WITNESS our signatures as acknowledged below. THE CONDITION OF THE ABOVE OBLIGATION IS AS FOLLOWS,
TO-WIT.
WHERE AS, t he above bound principal has appli ed for appoi ntment by the Gover nor of the St ate of Indiana as a
N o t a r y P u b l i c , i n a n d f o r t h e S t a t e o f I n d i a n a , f o r a e i g h t - y e a r t e r m .
Now, if the said principal shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to
law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective
date of the principal's commission to the expiration date of the same.
Signature of applicant. Must be acknowledged below in #11
Signature of surety. Must be acknowledged below in #12
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF ________________________________________, COUNTY OF __________________________________________________: SS:
County in which acknowledgement is being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
______________________________________________________________ and acknowledged the execution of the foregoing bond for the uses and
Printed or typed name of applicant
purposes therein expressed, without condition or reservation.
IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my
Place Officer's seal here
Printed or typed name of officer
hand and official seal, this ___________ day of ________________________________, 19 _______.
___________________________________________________________, a __________________________________
Signature of authorized officer
office
for the County of _____________________________________, State of ___________________________________.
Officer's county of residence
My commission expires: ______________________________________________________.
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge his/her own signature)
STATE OF ____________________________________________, COUNTY OF _____________________________________________ : SS:
County in which acknowledgement is being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
______________________________________________________________ and acknowledged the execution of the foregoing bond for the uses and
Printed or typed name of individual signing as surety
purposes therein expressed, without condition or reservation.
IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my
Place Officer's seal here
Printed or typed name of officer
hand and official seal, this ___________ day of ________________________________, 19 _______.
___________________________________________________________, a __________________________________
Signature of authorized officer
office
for the County of _____________________________________, State of ___________________________________.
Officer's county of residence
My commission expires: ______________________________________________________.
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF _____________________________________________ : SS:
County in which acknowledgement is being made
The undersigned surety, being duly sworn or affirmed, says that he/she is the owner in fee-simple of Real Estate in
_______________________________________ County, of the fair Cash Value of $ _______________________________ over and above all
encumbrances and exemptions.
Signature of surety
IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my
Place Officer's seal here
Printed or typed name of officer
hand and official seal, this ___________ day of ________________________________, 19 _______.
___________________________________________________________, a __________________________________
Signature of authorized officer
office
for the County of _____________________________________, State of ___________________________________.
Officer's county of residence
My commission expires: ______________________________________________________.
For the statute pertaining to surety company bonds, see Indiana Code 27-1-22. For the statutes pertaining to Officer's Bonds and
Oaths, see Indiana Code 5-4.
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