PAN-11 11-21
Pennsylvania
Association of Notaries
One Gateway Center, Suite 401
420 Fort Duquesne Boulevard
Pittsburgh, PA 15222-1498
phone: 800-944-8790
fax: 800-707-7075
E-mail: pan@notary.org
Notary Public Change of Name Order Form
Instructions for Changing Your Name on your Notarial Commission
You must report your new name to the Department of State within 30 days.
Complete the Department of State Change of Name form. Please provide proof of name change (i.e., marriage
certificate, marriage license, or proof of marriage from county office/court order/court order showing “Notice to
Retake Previous Surname” after divorce). Submit photocopies and this completed order form to PAN. We will
forward the copies to the Secretary of the Commonwealth.
When changing your name during your commission, you have two options:
1. Use your new name immediately:
1. Register your new signature with the prothonotary in the county where your office of record is located be-
fore using your new name. There may be a fee.
2. Purchase a new official stamp with your new name.
2. Continue using your old name until your commission expires and reapply using your new name
* Full agents and dealers should notify their insurance agent of their name change for bonding purposes.
CHECK ONE
q I have already sent a copy of the attached state form to the state.
q I authorize PAN to electronically transmit the information on the attached state form to the state for me.
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Signature
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Shipping and Handling
Name PAN Customer Number
Card Number
Name on Card
Expiration Date Security Code*
q Check enclosed, payable to “PAN”
(There is a $25 charge on all returned checks)
Charge to my:
q Visa q Discover q MasterCard q American Express
Card Holder’s Billing Address
City State ZIP
PAYMENT INFORMATION:
* The security code is a three- or four-digit number printed on the signature panel on the back of your credit card.
q Self-inking Notary Stamp..........Price: $15.95
q Pocket Embossing Seal ............Price: $21.95
Shipping & Handling
Add 7% Sales Tax
TOTAL AMOUNT DUE
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Choose Stamp Body Color:
q Blue q Green q Orange
q Pink q Purple q Red
q White q Yellow
PAN-11 11-21
Pennsylvania
Association of Notaries
One Gateway Center, Suite 401
420 Fort Duquesne Boulevard
Pittsburgh, PA 15222-1498
phone: 800-944-8790
fax: 800-707-7075
E-mail: pan@notary.org
Notary Public Change of Name Order Form
Commonwealth of Pennsylvania – Department of State
Bureau of Commissions, Elections and Legislation
Division of Commissions, Legislation and Notaries
210 North Office Building
Harrisburg, PA 17120
Tel: (717) 787-5280 Web: dos.pa.gov/notaries
NOTARY PUBLIC
CHANGE OF NAME
(Revised 8/1/2019)
A notary public must notify the Department of State within 30 days of any change in the information
on file with the Department, including the notary’s legal name. Such notice must be on a form
prescribed by the Department and accompanied by evidence of the name change (such as marriage
certificate, court order or divorce decree).
This form may be submitted online at www.notaries.pa.gov (link to “Update Notary Info”).
Following notification to the Department, the notary may use the new name or continue to perform
notarial acts in the name in which the notary was commissioned until the expiration of the notary’s
term. However, before using the new name on notarial work, the notary public must register the new
signature with the prothonotary’s office of the county where the notary’s office address is located
and purchase a new rubber stamp seal. Application for reappointment must be made in the new
name.
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.
PART I: Full name as it appears on your current commission:
First Name
Middle Name or Initial (if used)
Last Name
PART II: Name has changed to:
First Name
Middle Name or Initial (if used)
Last Name
Effective date of name change (mm/dd/yyyy): _________/________/________
Reason for change of name (circle one): Marriage / Divorce / Court Order / Other
_______________________________________________________________________
Please attach proof of name change (e.g. marriage certificate, court order, divorce decree)
APPLICANT DECLARATION: I shall furnish additional evidence of these statements, if requested, which shall be satisfactory to the Department of
State. 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 exactly match new name in Part II) Notary Printed Name (must match new name in Part II) Date
Notary commission expiration date
Date of Birth (mm/dd/yyyy)
Notary commission ID number
Email address where you can be contacted about this form
For Official Use Only