Notary Public Change Of Address

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Commonwealth of Pennsylvania – Department of State
Bureau of Commissions, Elections and Legislation
NOTARY PUBLIC
Division of Legislation and Notaries
CHANGE OF ADDRESS
210 North Office Building
(Revised 9/30/2011)
Harrisburg, PA 17120
Tel: (717) 787-5280 Web:
Section 7. Vacation of office; change of residence (57 P.S. § 153)
(a) In the event of any change of address within the Commonwealth, notice in writing or electronically
shall be given to the Secretary of the Commonwealth and the recorder of deeds of the county of original
appointment by a notary public within five (5) days of such change. For the purpose of this subsection,
"address" means office address.
PRINT OR TYPE CLEARLY. FILL OUT FORM COMPLETELY. Do not leave any blanks.
Use “none” or “N/A” if applicable. There is no fee for filing this form with the Department of
State. Please check with the applicable Recorder of Deeds office whether this form may be
used and for any recording fee.
Notary commission expiration date
Notary commission ID number
For Official Use Only
Full name as commissioned
Date of Birth (mm/dd/yyyy)
Email address where you can be contacted about
this form: _______________________________
Employer/Business Information of Record
Old Employer/Business Name
Employer/Business Street Address (P.O. Box alone is insufficient)
City
State
Zip Code
Employer/Business Telephone (include area code)
Municipality (city/borough/township)
County
New Employer/Business Information of Record (NOTE: Employer/Business contact information will be public record)
New Employer/Business Name
Employer/Business Street Address (P.O. Box alone is insufficient)
City
State
Zip Code
Employer/Business Telephone (include area code)
Municipality (city/borough/township)
County
Home Address of Record
Home Street Address (P.O. Box alone is insufficient)
City
State
Zip Code
Home Telephone (include area code)
Municipality (city/borough/township)
County
New Home Address of Record
Home Street Address (P.O. Box alone is insufficient)
City
State
Zip Code
Home Telephone (include area code)
Municipality (city/borough/township)
County
APPLICANT AFFIDAVIT: I shall furnish additional evidence of these statements, if requested, which shall be satisfactory to the Secretary of the Commonwealth. To the best of my knowledge
and belief, this filing contains no misrepresentations or falsifications, omission or concealments of material fact and the information given by me is true and complete. I understand that any
false statement made is subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities) and may result in the suspension, revocation, or denial of my notary
commission.
_____________________________________________________________________________
________________________________________________
Notary Signature (must match full name as commissioned)
Date

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