Form Nc - Notary Public Change Of Status - Kansas Secretary Of State

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Kansas Office of the Secretary of State:
kansas secretary of state
NC
Notary Public
Memorial Hall, 1st Floor
(785) 296-4564
Change of Status
120 S.W. 10th Avenue
notary@ks.gov
Topeka, KS 66612-1594
Print
Reset
Instructions: Complete the Name and Bond Number fields and proceed to section B.
Please complete the form, print, sign and mail to
A. Notary Information
the Kansas Secretary of State. Selecting 'Print' will
print the form and 'Reset' will clear the entire form.
Name
Bond number
(Print name under which your appointment is currently listed)
(Number listed on the appointment certificate)
B. Corrected Information
Instructions: Complete the fields that need to be changed. Fields left blank are presumed unchanged. Sign and date at
the bottom of the form.
1. Stamp change
(If requesting a name change,
complete fields 1 & 2.)
(Seal/Stamp)
2. Name change
Street Address
3. Residential address
(P.O. box is not acceptable.)
City
State
Zip
Street Address
4. Business address
(P.O. box is not acceptable.)
City
State
Zip
5. Daytime phone
6. Secondary phone
7. Miscellaneous
o
o
Check if you are canceling your bond.
Check if you need a new certificate sent.
I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and correct.
Signature of Notary
Month
Day
Year
1 / 1
Please review to ensure completion.
Rev. 8/24/16 tc

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