Affirmation For Appointment And Commission As A Notary Public

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Affirmation for Appointment and Commission as a Notary Public
Colorado Secretary of State
Notary Program
Phone: 303-894-2200, press 4, then 1
1700 Broadway, Ste. 200
Fax: 303-869-4864
Denver, CO 80290
, solemnly affirm, under the penalty of
Print legal name
perjury in the second degree, as defined in section 18-8-503, Colorado Revised Statutes, that I have
carefully read the notary law of this state, and if appointed and commissioned as a notary public, I
will faithfully perform, to the best of my ability, all notarial acts in conformance with the law.
I am (mark one):
a United States citizen
a legal permanent resident of the United States
lawfully present in the United States pursuant to federal law.
I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States prior
to receipt of this public benefit. I further acknowledge that knowingly making a false, fictitious, or
fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of
Colorado as perjury in the second degree under section 18-8-503, Colorado Revised Statutes, and it shall
constitute a separate criminal offense each time a public benefit is received based on such statement or
Applicant’s signature
Subscribed and affirmed before me in the county of
, state of Colorado,
day of
, 20
Official signature of Notary Public or other qualified person
(Notarial seal)
Commission expiration date
Page 1 of 1
Rev. 5/03/2013


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