STATE OF IDAHONOTARY PUBLIC COMMISSIONNAME OR ADDRESS CHANGE

611

This block for Secretary of State use only.

DO NOTSTAMP, WRITE,

OR SIGNIN THIS

AREA

Notary Signature:

Rev. 07/2017

NAME CHANGE: Enter your name exactly as it will appear on your new notary seal.First Name: Middle Name or Initial (if used):Last Name: Suffix (Jr., Sr., ect.):

Physical Address (not a PO Box): City: State: Zipcode:CHANGE PHYSICAL ADDRESS: Enter your new physical address. This must be a street address, not a PO Box.

Name and Mailing Address (if different from physical address): City: State: Zipcode:CHANGE MAILING ADDRESS: Enter your new mailing address. Include a name, if different than your own.

Fees: Name or Physical Address Change – $5.00 Mailing Address Change Only – No Charge

Submit this form with payment to:Idaho Secretary of StatePO Box 83720Boise, ID 83720-0080

SELECT CHANGE(S): Name ChangeChange Physical Address Change Mailing Address

If yes, government agency name: Agency phone:

Yes NoAre you a city, county, or state government employee?Government employment: If you can truthfully answer "yes," there is no fee for filing this form.

Commission Number:

First Name: Middle Name or Initial (if used):Last Name: Suffix (Jr., Sr., ect.):CURRENT COMMISSION NAME :

Find your commission number at: http://www.sos.idaho.gov/NotarySearch/