Name as it appears on your commission
Additional name(s) commissioned under
Date commission issued _____________________________________________________________________
County ____________________________________ Date of Birth ________________________________
Email (Optional) ____________________________ Phone Number _______________________________
Mark all boxes that apply:
Change Seal:
I would like to use the new notary seal imprint shown. I
intend to use both the new seal and my current notary seal.
When I renew my commission, I am aware I will need to
place an imprint of both notary seals on the application.
I would like to discontinue the use of my current notary seal
on file and use the imprint of the new notary seal shown.
Change Name:
I would like to change my name on my notary public commission and will use the imprint of the
new notary seal above. Complete the following:
Date of name change
Changed by Court Order Marriage
New name
(as it appears on new notary seal)
Change Address:
I would like to change my physical address on file to the address below.
____________________________________________________________________________________
Physical Address City State Zip County
I would like to change my mailing address on file to the address below.
____________________________________________________________________________________
Mailing Address City State Zip County
I hereby state that the above information is true and correct. I understand that I will not be able to
use a new notary seal imprint until I am notified by the Secretary of State.
Dated ________________________________
_______________________________________________
(Signature EXACTLY as found on your seal imprint)
Notary Public Request to Change Record
Please Type or Print Clearly in Ink
No Filing Fee
Return to: Secretary of State, 500 East Capitol Ave, Pierre, SD 57501
Make Imprint of New Seal Here
FOR INTERNAL OFFICE USE ONLY
File Date: ______________________
Commission Date: _______________
Notary ID: ______________________
