Additional information

Surety Company	Travelers Surety, Western Surety Company
Bond Term	4-year
Errors and Omissions (E&O)	Bond Only, $10,000, $15,000, $20,000, $25,000, $30,000, $35,000, $50,000, $100,000

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Notary Public kansas secretary of state
Appointment Form Memorial Hall, 1st Floor (785) 296-4564
120 S.W. 10th Avenue notary@ks.gov
Topeka, KS 66612-1594 sos.ks.gov
Form NO

IMPORTANT: This form must be submitted by mail and include the ling fee. If renewing a notary commission, please do not submit the
form before 90 days prior to your current commission expiration date. Once you are a Kansas notary and want to add IPEN or RON to your
existing notary commission, please complete Form NC.

Expiration date of your most recent Kansas appointment: (Search Here) Current or most recent commission number: (Search Here)
Month Day Year

(Your current commission expiration date must be used until the date of expiration has
passed.)

A. Personal Information
1. Applicant’s name (Must match name on the stamp in Item 5.) Previous name (If your name has changed from the previous appointment.)
First Middle Last

2. Mailing address (Must be an address located either in Kansas or a 3. Phone number (Required)
bordering state)
Mailing Address Primary

City State Zip Secondary (Optional)

4. Email (Optional)

5. Afx an impression of applicant’s stamp
(Name on stamp must match applicant’s name in Item 1. Include all stamps that will be used during this commission. You may include an attached page for additional stamps.)
a. Stamps for tangible (paper) documents. Required before submitting application.

6. Notary Eligibility (This section must be completed.)

a. Are you at least 18 years of age
o Yes o No
b. Are you a resident of Kansas Or, are you a resident of a state bordering Kansas with a regular place of employment or
practice in Kansas If you meet either of these requirements, check “Yes.” o Yes o No
c. Are you able to read and write the English language
o Yes o No
d. Have you been convicted of any felony or a crime involving fraud, dishonesty or deceit, including entering into a diversion
agreement in lieu of further criminal proceedings for such crime o Yes o No
e. Have you had a professional license denied, revoked, or suspended, if such denial, revocation, or suspension was for fraud,
dishonesty, deceit or any cause substantially relating to the duties or responsibilities of a notary public o Yes o No
f. Have you had a notary public commission in another state that has been denied, refused for renewal, revoked, suspended, or
conditioned o Yes o No

1 / 3 K.S.A. 53-103 Continue to next page
Rev. 6/21/22 tc
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B. Oath
I do solemnly swear* (I sincerely and truly declare and afrm), under penalty of perjury, that the answers to all questions on this
application are true and complete to the best of my knowledge, and that I am qualied to be appointed and commissioned as a
Kansas notary public.
* The applicant may say the phrase inside the parentheses instead of the words in bold.
7. Applicant’s signature (must be a wet ink signature, or provide a wet ink signature on an attached page if signed electronically)

X
8. To be completed by the notary who witnesses the applicant’s signature: (See sample in the Kansas Notary Public Handbook page 23)

a. State of

County of

b. Signed and sworn to (or afrmed)
before me on
by
Date Name of person swearing oath (#7)
Name of applicant (#1)

c. Signature of notary

(Notary Stamp)
d. My commission expires:

Date

C. Notary Surety Bond (The surety company must complete this section.) Bond No. ________________

9. Name and address of surety company
Name

Street Address

City State Zip

Know All Persons By These Presents: That we, the above-named applicant as principal and as surety company, give bond payable to any individual who may be
harmed as a result of a breach of duty by said applicant acting in his/her ofcial capacity as notary public, in the amount of twelve thousand dollars ($12,000) as
assurance for the due discharge of the duties of his/her ofce of notary public and we do bind ourselves, and each of our heirs, executors and administrators,
jointly and severally. Applicant was, on the date of issuance of commission, bonded as a notary public in and for the state of Kansas, to hold ofce for the term
of four years in accordance with the laws of this state. Now, therefore, if said applicant shall faithfully discharge the duties of the ofce of notary public, as
prescribed by law, then this obligation shall be void. Further, we, the surety company, understand that we are required by state law to report to the secretary of
state the outcome on any claim led on this bond.
10. Attorney-in-Fact Signature

X
(Corporate Seal)
Date
Month Day Year

2 / 3 K.S.A. 53-103 Continue to next page
Rev. 6/21/22 tc
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Checklist for Notary Applicants
1. Completed Form NO. Please ensure that:
all questions are answered
an image of the notary’s stamp(s) is(are) included
the oath section is properly completed
the application is signed by the attorney-in-fact of the notary’s surety company (Section C)
the surety bond (Section C) is completed by the surety company
2. Correct notary fee is included.

3 / 3 K.S.A. 53-103 Please review to ensure completion.
Rev. 6/21/22 tc
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kansas secretary of state The following form must be
Form Notary Public complete and accompanied by the
NO Appointment Form correct filing fee or the document
Instructions will not be accepted for filing.

IMPORTANT:
This appointment form must be submitted by mail with the ling fee.
If renewing your notary appointment, please do not submit this form more than 90 days prior to your commission expiration date.
You are not a notary until your online notary status is active. (Search Here)
To register to perform in-person electronic notarizations (IPEN) or remote online notarizations (RON), submit the Form NC after
the appointment form has been approved and led.

General Information (required before submitting)
Filing fee Submit this form with the $25 ling fee for the notary appointment form.
Payment The appointment form must be submitted with either check or money order and must be made payable to
the Kansas Secretary of State. Please do not send cash.

The option to pay by credit card is available to (online submissions) only.

Section A. Personal Information (required before submitting)
Expiration date If the applicant is currently, or has previously been a Kansas notary, enter the most recent expiration date
and commission number. Online search is available here.
Applicant name The name in item 1 must match exactly the name printed on the notary stamp in item 5. (Prexes or titles
(Doctor, Father, Mrs.) are not allowed). To use initials for the rst name, you must submit a photo copy
of a government-issued ID that shows an initial as a rst name. It is recommended that the name on the
application be listed as it is listed on the applicant’s state-issued driver’s license or identication card.
Sufxes that show a professional certication are not allowed (e.g., CPA, Esq., JD).
Mailing address Provide a mailing address that is located either in Kansas or a bordering state where the notary receives
mail.
Phone number Enter the applicant’s primary and secondary (if any) telephone number.
Ofcial stamp Afx an impression of the notary stamp that the applicant will use to notarize paper documents during the
commission for which the applicant is applying. If the applicant chooses to use more than one stamp, an
impression of each must appear in the space provided or on an attached page. The applicant may either use
a “seal press” (impression seal) with the impression inked or used with foil seals, or a rubber stamp to
be used with permanent ink.

The tangible stamp must include:
The applicant’s name that identically matches the name on the notary application in Item 1.
The words “Notary Public” and “State of Kansas”.
It may include the following phrase or a phrase that is substantially similar: My Commission Expires
(date).

Do not include the county within the stamp. Although you must obtain your stamp before completing the
appointment process, you will not be authorized to notarize documents until your online notary status is
active (Search Here). The name on the stamp must match identically, including punctuation, the
name entered on the appointment form in item 1.
Notary eligibility If answering “No” to questions a, b, or c, the applicant is not eligible to be a notary. If answering “Yes” to
questions d, e, or f, include court documents for our legal division to review.

K.S.A. 53-103 Continue to next page
Inst. Rev. 6/21/22 tc
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kansas secretary of state
Form Notary Public
NO Appointment Form
Instructions

Section B. Oath (required before submitting)
Oath The applicant must sign the appointment form after reciting the oath in the presence of a notary public.
The afrmation statement in parentheses may be recited instead of the bolded words in the oath.
Signature A sample of a wet ink signature is required from the applicant. This includes if the oath is remotely or
electronically notarized. Attach a page with a wet ink signature if signing electronically.
Notarization of applicant’s The applicant’s signature must be notarized. A notary must complete the notarization below the applicant’s
signature signature.

Section C. Notary Surety Bond (required before submitting)
Surety bond A notary public is required to be bonded in the sum of $12,000 for a four (4) year period coinciding with
the appointment. The bond must be a commercial surety bond from an insurance company licensed to do
business in Kansas. The surety company must complete this section.
Surety name and address The surety company enters its name and address.
Surety signature The signature is completed by the Attorney-in-Fact from the surety company and includes the date the
bond was signed. A surety company must afx a corporate seal or attach its Power of Attorney. No other
information is required to be submitted to the Kansas Secretary of State’s Ofce. Do not include error and
omissions policy documents.

Additional Information: Please review the Kansas Notary Public Handbook for more information regarding
Kansas notaries.

Please le Form NC online to:
Change a name Change a stamp or report a stamp lost or stolen
Change an address Change or update surety bond information
Terminate a notary commission Add an IPEN or RON registration to an existing notary com-
Report a journal lost or stolen mission

K.S.A. 53-103 Please proceed to form.
Inst. Rev. 6/21/22 tc

Travelers Casualty and Surety Company
Travelers Casualty and Surety Company of America
One Tower Square, Hartford, Connecticut 06183

NOTARY PUBLIC ERRORS AND OMISSIONS POLICY
Policy No.
Term Premium:
Policy Effective Date:

The Company will pay on behalf of of
(the “Insured”), all sums which the Insured shall become
obligated to pay by reason of liability for breach of duty while acting as a duly commissioned and sworn Notary Public, claim for which is made
against the Insured by reason of any negligent act, error or omission, committed or alleged to have been committed by the Insured, arising out of the
performance of notarial service for others in the Insured’s capacity as a duly commissioned and sworn Notary Public.

POLICY PERIOD: This policy applies only to negligent acts, errors or omissions which occur during the Policy Period and then only if
claim, suit or other action arising therefrom is commenced within the applicable Statute of Limitations pertaining to the Insured. The Policy Period
commences on the Effective Date hereof and terminates upon the expiration of the Insured’s commission as a Notary Public unless cancelled earlier
as provided in this policy. This policy is not valid for more than one commission term.

LIMIT OF LIABILITY: The liability of the Company shall not exceed in the aggregate for all claims under this insurance the amount of:
$5,000 (Five Thousand) DOLLARS
$10,000 (Ten Thousand) DOLLARS
$15,000 (Fifteen Thousand) DOLLARS
$20,000 (Twenty Thousand) DOLLARS
$25,000 (Twenty Five Thousand) DOLLARS
$30,000 (Thirty Thousand) DOLLARS

$50,000 (Fifty Thousand) DOLLARS

$100,000 (One Hundred Thousand) DOLLARS

In addition to the limit of liability and in accordance with the other provisions of this policy, the Company will pay costs and expenses paid and
incurred in investigating, contesting or settling liability in an amount not to exceed, in the aggregate, one-half of the limit of this policy.

INSURED’S DUTIES IN THE EVENT OF OCCURRENCE, CLAIM OR SUIT:
(a) Upon knowledge of any occurrence which may reasonably be expected to result in a claim or suit, written notice containing
particulars sufficient to identify the Insured and also reasonably obtainable information with respect to the time, place and circumstances thereof,
and the names and addresses of the potential claimant and of available witnesses, shall be given by or for the Insured to the Company or any of its
authorized agents as soon as practicable, but in no event longer than forty-five (45) days after discovery.
(b) If claim is made or suit is brought against the Insured, the Insured shall immediately forward to the Company every demand,
notice, summons or other process received by him or his representative.
(c) The Insured shall cooperate with the Company and, upon the Company’s request, assist in making settlements, in the conduct
of suits and the Insured shall attend hearings and trials and assist in securing and giving evidence and obtaining the attendance of witnesses. The
Insured shall not, except at his own cost, voluntarily make any payment, assume any obligation or incur any expense except with the prior written
consent of the Company.

EXCLUSIONS: Coverage under this policy does not apply to any dishonest, fraudulent, criminal or malicious act or omission of
the Insured.

OTHER INSURANCE: If the Insured has other insurance against a loss covered by this policy, the Company shall not be liable under this
policy for a greater proportion of such loss, cost and expenses than the limit of liability stated in this policy bears to the total limit of liability of all
valid and collectible insurance against such loss.

CANCELLATION: The insured may cancel this policy at any time by mailing or delivering to us advance written notice of cancellation.
The company may cancel this policy by mailing or delivering to the insured written notice of cancellation at least 10 days before the effective date of
cancellation if we cancel for nonpayment of premium or 30 days before the effective date of cancellation if we cancel for any other reason. If we
cancel, the premium refund will be pro rata and if the insured cancels, the refund may be less than pro rata. The cancellation will be effective even if
we have not made or offered a refund.

Dated, signed and sealed this .

By
Authorized Representative

E-1001A (01/05)
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ISSUED BY: POLICY NO:
ISSUED TO:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION/NONRENEWAL – Kansas
FULL CANCELLATION – INSURER

It is agreed that:

1. The policy provisions regarding cancellation by the Company are deleted and replaced with the following:

A. CANCELLATION OF POLICIES IN EFFECT FOR 90 DAYS OR LESS
If this Policy has been in effect for 90 days or less and is not a renewal of a policy we issued, we may cancel this Policy
for any reason. We will mail or deliver written notice of cancellation to the entity named in Item 1 of the Declarations at
least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or
(2) 20 days before the effective date of cancellation if we cancel for fraud or misrepresentation; or
(3) 30 days before the effective date of cancellation if we cancel for any other reason.

B. CANCELLATION OF POLICIES IN EFFECT FOR MORE THAN 90 DAYS
If this Policy has been in effect for more than 90 days, or is a renewal of a Policy we issued, we may cancel only for one
or more of the following reasons:
(a) Nonpayment of premium;
(b) Substantial change in the scale of risk covered by the policy;
(c) Fraud or material misrepresentation committed by the insured, upon the insurer;
(d) Failure to comply with reasonable safety recommendations; or
(e) Reinsurance of the risk associated with the policy has been cancelled.

We will mail or deliver written notice of cancellation under this item B., to the entity named in Item 1 of the
Declarations at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or
(2) 20 days before the effective date of cancellation if we cancel for fraud or material misrepresentation; or
(3) 45 days before the effective date of cancellation if we cancel for a reason described in B.(b), (d) or (e) above.

2. The following is added and supersedes any other provision to the contrary:

NONRENEWAL
A. If we decide not to renew this Policy, we will mail or deliver written notice of nonrenewal to the entity named in Item 1 of
the Declarations, at least 45 days before its expiration date, or its anniversary date if it is a Policy written for a term of more
than one year or with no fixed expiration date.

3. Proof of mailing is sufficient proof of notice.

Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, exclusions or limitations of the
above mentioned policy, except as expressly stated herein. This endorsement is effective at the inception date stated in the
Declarations and this endorsement is part of such policy and incorporated therein.

ILT-5028 (06-04)
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ISSUED BY: POLICY NO:
ISSUED TO:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION/NONRENEWAL – Kansas
CANCELLATION FOR NONPAYMENT OF PREMIUM

It is agreed that:

1. The policy provisions regarding cancellation by the Company are deleted and replaced with the following:

A. We may cancel this Policy for nonpayment of premium by mailing or delivering to the entity named in Item 1 of the
Declarations written notice of cancellation at least 10 days before the effective date of cancellation.

2. The following is added and supersedes any other provision to the contrary:

NONRENEWAL
A. If we decide not to renew this Policy, we will mail or deliver written notice of nonrenewal to the entity named in Item 1 of
the Declarations, at least 45 days before its expiration date, or its anniversary date if it is a Policy written for a term of more
than one year or with no fixed expiration date.

3. Proof of mailing is sufficient proof of notice.

Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, exclusions or limitations of the
above mentioned policy, except as expressly stated herein. This endorsement is effective at the inception date stated in the
Declarations and this endorsement is part of such policy and incorporated therein.

ILT-5029 (06-04)