Notary Public Change of Name Form Updated 11/2019
Notary Public Change of Name Form
Filing Fee $15.00
Complete this form and send the signed original to the above address, along with a nonrefundable
statutory fee of $15.00. Make check payable to “Secretary of the State”. Do not send cash. This
document must be notarized below.
Date: Phone:
(Your new certificate will be emailed to this email address)
Notary Account Number: Date Commission Expires:
Previous Name of Notary Public:
(Name that appears on your current notary public certificate)
New Name of Notary Public:
(This is the name that will appear on your new certificate)
Reason for Change of Name (check one):
Petition to Change Name
Other (explain)
Applicant’s Signature _____________________________________________________________
Subscribed and sworn to before me this___ day of ___________, 20____
Signature of Notary Public Date Commission Expires: ____________________
Printed Name of Notary Public
Office of the Secretary of the State
State of Connecticut
P.O. Box 150470, Hartford, CT 06115-0470
Notary Public Unit