Change of Address
Uploaded by
The Pennsylvania NotaryChange of Address
Uploaded by
The Pennsylvania NotaryCommonwealth of Pennsylvania Department of State
Bureau of Commissions, Elections and Legislation Division of Legislation and Notaries 210 North Office Building Harrisburg, PA 17120 Tel: (717) 787-5280 Web: http://www.dos.state.pa.us/notaries
NOTARY PUBLIC
CHANGE OF ADDRESS (Revised 9/30/2011)
Section 7. Vacation of office; change of residence (57 P.S. 153) (a) In the event of any change of address within the Commonwealth, notice in writing or electronically shall be given to the Secretary of the Commonwealth and the recorder of deeds of the county of original appointment by a notary public within five (5) days of such change. For the purpose of this subsection, "address" means office address.
PRINT OR TYPE CLEARLY. FILL OUT FORM COMPLETELY. Do not leave any blanks. Use none or N/A if applicable. There is no fee for filing this form with the Department of State. Please check with the applicable Recorder of Deeds office whether this form may be used and for any recording fee.
Notary commission expiration date Full name as commissioned Notary commission ID number
For Official Use Only
Date of Birth (mm/dd/yyyy)
Email address where you can be contacted about this form: _______________________________
Employer/Business Information of Record
Old Employer/Business Name Employer/Business Street Address (P.O. Box alone is insufficient) Employer/Business Telephone (include area code) City Municipality (city/borough/township) State County Zip Code
New Employer/Business Information of Record (NOTE: Employer/Business contact information will be public record)
New Employer/Business Name Employer/Business Street Address (P.O. Box alone is insufficient) Employer/Business Telephone (include area code) City Municipality (city/borough/township) State County Zip Code
Home Address of Record
Home Street Address (P.O. Box alone is insufficient) Home Telephone (include area code) City Municipality (city/borough/township) State County Zip Code
New Home Address of Record
Home Street Address (P.O. Box alone is insufficient) Home Telephone (include area code) City Municipality (city/borough/township) State County Zip Code
APPLICANT AFFIDAVIT: I shall furnish additional evidence of these statements, if requested, which shall be satisfactory to the Secretary of the Commonwealth. To the best of my knowledge and belief, this filing contains no misrepresentations or falsifications, omission or concealments of material fact and the information given by me is true and complete. I understand that any false statement made is subject to the penalties of 18 Pa. C.S. 4904 (relating to unsworn falsification to authorities) and may result in the suspension, revocation, or denial of my notary commission.
_____________________________________________________________________________ Notary Signature (must match full name as commissioned)
________________________________________________ Date
Notary Public Change of Address Addendum
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FOR RECORDER OF DEEDS USE ONLY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - State of ________________________________ County of _______________________________
This acknowledgement is not required to be executed for filing this form with the Department of State. However, an acknowledgment may be required prior to recording with the applicable Recorder of Deeds office, if that Recorder of Deeds office accepts this notary public change of address form.
On this, the ________ day of ___________________, 20____, before me _____________________________, the undersigned officer, personally appeared ____________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that ____________________________ executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. _____________________________________ _____________________________________ Title of Officer
