Free 40889.PDF - Indiana

Sta te Form 40889 (R7 / 1-03) Approved by State Board of Accounts , 1997

TODD ROKITA SECRETARY OF STATE

NOTARY PUBLIC APPLICATION*

Including: Request to be appointed a Notary Public Notarial Oath Notarial Bond Instructions

IC 33-16-2-1: (as amended) Sec. 1 (a) Any applicant for a commission as a notary public shall possess the following qualifications: (1) be at least eighteen (18) years of age; and (2) be a legal resident of the State of Indiana. ( b ) A n o t ar y p u b l i c sh al l b e ap p o i n t ed a n d co m m is si o n ed b y t h e G o v er n o r. A n o t ar y p u bl i c s h al l h o l d office for eight (8) years. A notary public, when so qualified, shall be authorized to act within the State of Indiana. A person may request an application to become a notary public from the Secretary of State. The application shall be prescribed by the Secretary of State and shall include the applicant's county of residence, oath of office, and official bond. The application shall also contain any additional information necessary for the efficient administration of this chapter. The applicant shall personally appear, with an application, before an officer authorized by law to administer oaths who shall administer an oath of office to the applicant. The applicant shall secure an official bond, with freehold or corporate security, to be approved by the Secretary of State in the sum of five thousand dollars ($5,000). The official bond shall be conditioned upon the faithful performance and discharge of the duties of the office of notary public, in all things according to law, for the use of any person injured by a breach of the condition. The completed application shall be forwarded to the Secretary of State. The Secretary of State shall forward each commission issued by the Governor to the applicant or the applicant's surety company.

Notary Department Secretary of State's Office Room 201 State House Indianapolis, Indiana 46204 317-232-6542

* T h i s ap p l i cat i o n sh o u l d al s o b e f i l l ed o u t b y cu r r en t n o t ari e s p u b l i c d esi r i n g t o ex t e n d t h ei r co m mi s si o n f o r an o t h er t er m . Th er e i s n o se p ara t e re n ew al fo r m o r p r o ced u r e.
IT IS A CRIME TO PERFORM ANY OF THE DUTIES OF A NOTARY PUBLIC U NTIL COMMISSIONED BY THE GOVERNOR. IT IS IMPORTANT THAT YOU POSSESS A CURRENT, VALID COMMISSION BEFORE ACTING AS A NOTARY PUBLIC. THE FILING OF THIS APPLICATION OR THE TAKING OF THE OATH CONTAINED AS PART OF THIS APPLICATION DOES NOT AUTHORIZE YOU TO ACT AS A NOTARY PUBLIC.

NOTARY APPLICATION INSTRUCTIONS
1. Appl ication for Notary Public may be obtained fr om th e Secretary o f State, the C lerk of the C ircu it C ourt , or a bonding company. Applications can be p hotocop ied if all parts of the applicatio n remain o n the front and back of one piece of paper. T h e a pp l i ca t i o n m u s t be f i l l e d o u t co m p l et e l y. T h e a p p l i ca t i o n mu s t b e t y p e w ri t t e n o r p ri n t e d . D o no t l e a v e a n y b l a n k s . I f a n y i t em i s n o t a p p l i ca b l e t o y o u , p l e a se i n d i ca t e t h a t f a ct w i t h t h e w o rd s "n o t a p p l i c a b l e" o r " n o n e " o r "N A ". In giving your name in item #1 on the application, you should print or type your name the way you will sign your name as a notary public. Your first or middle name may be initialed, but we suggest either your first full name or your second full name or both, whichever you prefer. For example: John S. Smith, J. Samuel Smith, or John Samuel Smith; but not J. S. Smith. Your commission will be issued in the name given in item #1 and when performing a notarial act you should always sign your name the way it appears on your commission. This requirement is for identification purposes and is for your protection. If you are makin g reapplication, it is imp ortant for y ou to complete item #7 on the application and show yo ur expiration date so that when your new commission is issued there will be no lapse or overlap. (If your commission has recently expired, do not show your old expiration date in #7. Show an expiration date only if your commission is still in effect when you complete the application.) Reapplications should not be sent to the Secretary of State's office earlier than sixty (60) days before the expiration date. After the first seven items of the application have been filled out, take the application to an officer authorized by law to administ er oaths (e.g. another notary public, th e C lerk of the C ircuit Co urt, etc.). The oath of office (item #9 of t he appl ica tion) wil l b e admin istered to you by that o fficer. B e su re to read i nstruct ions #6, 7 , 8, 9 and 10 below.
PLEASE NOTE: BEFORE TAKING THE OATH IT IS IMPORTANT TO DETERMINE IF YOU ARE QUALIFIED TO BE A NOTARY PUBLIC. A. INDIANA LAW STATES THAT IT SHALL BE AN INDISPENSABLE QUALIFICATION FOR PERSONS TO HOLD ANY OFFICE WITHIN THE STATE OF INDIANA, EITHER BY ELECTION OR APPOINTMENT, THAT SUCH PERSONS SHALL NEVER HAVE BEEN CONVICTED OF ANY CRIME AGAINST THE LAWS OF THE UNITED STATES WHERE THE SENTENCE IMPOSED EXCEEDED SIX (6) MONTHS (IC 5-8-3-1). B. NO PERSON HOLDING ANY LUCRATIVE OFFICE OR APPOINTMENT UNDER THE UNITED STATES OR UNDER THIS STATE, AND PROHIBITED BY THE CONSTITUTION OF THIS STATE FROM HOLDING MORE THAN ONE SUCH LUCRATIVE OFFICE, SHALL SERVE AS A NOTARY PUBLIC, AND HIS ACCEPTANCE OF ANY SUCH OFFICE SHALL VACATE HIS APPOINTMENT AS SUCH NOTARY; BUT THIS PROVISION SHALL NOT APPLY TO ANY PERSON HOLDING ANY LUCRATIVE OFFICE OR APPOINTMENT UNDER ANY CIVIL OR SCHOOL CITY OR TOWN OF THIS STATE. (IC 33-16-2-7) C. EVERY PERSON ELECTED OR APPOINTED TO ANY OFFICE UNDER THIS CONSTITUTION SHALL, BEFORE ENTERING ON THE DUTIES THEREOF, TAKE AN OATH OR AFFIRMATION TO SUPPORT THE CONSTITUTION OF THIS STATE, AND OF THE UNITED STATES, AND ALSO AN OATH OF OFFICE. (Indiana Constitution, Article 15, Section 4)

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7. 8.

9. 10.

An of ficial bo nd, with freehold o r corpo rate securit y, must be secu red i n the sum of $ 5,000. The app licant must sig n in item #10 and hav e his signat ure acknowledged in #11. (Freeho ld security must be approved by the Secretary of State and item #13 of the application is only compl eted i n the case of a freeh old bond. A freeh old bond is when someon e o ther than th e appli can t, who own s land wort h at least $5,000, is the suret y.) Corpo rate secu rity can be obtain ed by taki ng the app lication t o a b onding compan y for co mp letio n. Insurance co mpanies and agents are often q ual ified to prov ide cor porate secu rity. Items #1 0, 11 and 12 of th e appli catio n mak e up the bon d. In the case of a corporate security, a power of attorney showing that the individual signing for the bonding company has aut hority to execute th e bond shoul d be at tached to th e app lication wh en it is su bmitted to the Secret ary of State. The completed application, including the oath of office and bond, should be forwarded to the Secret ary of State with a fee of five dollars ($5), payable to the Secretary of State, in the form of a check or money order. Do not send currency in the mail. Th e S ecr et ary o f St at e wi l l f o rw ar d y o u r co mm i ssi o n t o yo u (o r t o y o u r su r et y co m pan y, i f r eq u est ed t o d o so by en cl os i ng a s el f- ad dr es sed r et u r n en v el o pe w i t h t h e ap p l i cat io n . ) Please tear off and keep these instructions.

Do Not Write In This Box - For Office Use Only

Commission # _________________________________ Expiration Date of New Commission ___________________________________________

APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House Indianapolis, Indiana 46204: Telephone: 317-232-6542

To: THE GOVERNOR OF INDIANA I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond, oath of office, and fee of FIVE DOLLARS ($5), payable to the Secretary of State, in the form of a check or money order. (Do not send currency in the mail.) (IC 33-16-2-1)

PRINT OR TYPE
1. 2. NAME __________________________________________________________________________________________________________
Your legal signature in which commiss ion will be issued - s ee instruction #3

HOME ADDRESS __________________________________________________________________________________________________
Number and s treet

__________________________________________________________________________________________________________________
City State ZIP code

3. 4. 5. 6. 7.

COUNTY OF RESIDENCE _______________________________________________________________________________________ Business or Employer's Name _____________________________________________________________________________________ Business or Employer's Address ___________________________________________________________________________________
Street City State ZIP code

( ) HOME PHONE _______________________________________
Area Code Number

( ) OFFICE P HONE ________________________________________
Area Code Number

If you have a current valid notary commission, show your expiration date: __________________________________, 20 _______

8.

If you are now a notary public and your name or county has changed since your last application, please give both old and new information. OLD: ___________________________________________________________________________________________________________ NEW: __________________________________________________________________________________________________________

9.

NOTARIAL OATH STATE OF INDIANA COUNTY OF _______________________________
County in which oath is administered

) SS: )

I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of Indiana; that I am duly qualified to hold office under the Constitution and laws of the State; that I am 18 years of age or over; that I am of good moral character and integrity; that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have carefully read all of the instructions which came with this application, and that I will faithfully and impartially discharge the duties of NOTARY PUBLIC if so commissioned by the Governor, according to the best of my skill and ability, so help me God (or under the pains and penalties of perjury).

Signature of applicant

Place Of fice r's Se al He re

Subscribed and sworn or affirmed to before me, this _____ day of ________________________________________ A.D. 20 _____. IN TESTIMONY WHEREOF, I, _____________________________________________________
Printed o r typed name of o fficer

______________________________________________, a ________________________________________ for the
Signature of a notary public or other officer authorized to administer oaths Office

County of ___________________________________________, State of Indiana.
Officer's coun ty of residen ce

My commission expires: _________________________________________________ NOTE: The Bond Form, starting with #10 on the back of this application, must be completed before mailing to the S ecretary of State. The applicant must sign again in #10.

10. NOTARIAL BOND KNOW ALL BY THESE PRESENTS, that we _________________________________________________________________________ as principal
Name of Applicant

(applicant) and _________________________________________________________________________________________________________ of
Name of Surety

__________________________________________________________________________ and _________________________________ County as
Street address, city, s tate & ZIP code

freehold or corporate surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), the payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents. WITN ESS our signatures as ac knowl edged below. THE CO NDITIO N OF THE ABO VE O BLIG ATION IS AS F OLL OWS , TO-WIT. W H ER EA S , t he a bo ve bo und pr in c ip al h as ap pl ie d fo r a pp oi nt me nt b y th e G ove r nor o f t he S t a te o f I ndi a na a s a N ot a ry P ub li c , i n an d f or t he S t at e of In di an a, f or a ei gh t- ye ar t er m . Now, if the said principal shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective date of the principal's commission to the expiration date of the same.
Signature of applicant. Must be acknowledged below in #11 Signature of surety. Must be acknowledged below in #12

11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. STATE OF ________________________________________, COUNTY OF __________________________________________________: SS:
County in which acknowledgement is being made

Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared ______________________________________________________________ and acknowledged the execution of the foregoing bond for the uses and
Printed or typed name of applicant

purposes therein expressed, without condition or reservation.
Place Of fice r's seal here

IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my
Printed or typed name of officer

hand and official seal, this ___________ day of ________________________________, 20 _______. ___________________________________________________________, a __________________________________
Signature of authorized officer Officer's county of res idence office

for the County of _____________________________________, State of ___________________________________. My commission expires: ______________________________________________________. 12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge his/her own signature) STATE OF ____________________________________________, COUNTY OF _____________________________________________ : SS:
County in which acknowledgement is being made

Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared ______________________________________________________________ and acknowledged the execution of the foregoing bond for the uses and
Printed or typed name of individual s igning as surety

purposes therein expressed, without condition or reservation.
Place Of fice r's seal here

IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my
Printed or typed name of officer

hand and official seal, this ___________ day of ________________________________, 20 _______. ___________________________________________________________, a __________________________________
Signature of authorized officer Officer's county of res idence office

for the County of _____________________________________, State of ___________________________________. My commission expires: ______________________________________________________. 13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY. STATE OF INDIANA, COUNTY OF _____________________________________________ : SS:
County in which acknowledgement is being made

The undersigned s urety, being duly s worn or affirmed, s ays that he/she is the owner in fee-simple of Real Estate in _______________________________________ County, of the fair Cash Value of $ _______________________________ over and above all encumbrances and exemptions.
Place Of fice r's seal here
Signature of surety

IN TESTIMONY WHEREOF, I ___________________________________________________, have hereunto set my
Printed or typed name of officer

hand and official seal, this ___________ day of ________________________________, 20 _______. ___________________________________________________________, a __________________________________
Signature of authorized officer Officer's county of res idence office

for the County of _____________________________________, State of ___________________________________. My commission expires: ______________________________________________________. For the statute pertaining to surety company bonds, s ee Indiana Code 27-1-22. For the statutes pertaining to Officer's Bonds and O aths , see Indiana Code 5-4.