NOTARY BOND For Office Use Only
SECRETARY OF STATE ID Number:
Secretary of State
State of North Dakota
600 E Boulevard Ave Dept 108
Bismarck ND 58505-0500
Telephone: (701) 328-2901
Bond number Toll-Free: (800) 352-0867, option 7
Website: sos.nd.gov

Instructions:
1. This surety bond must be in the amount of $7,500.00 and must cover notarial acts performed during the term of the notary public’s
commission. It may be obtained from any surety company of the applicant’s choice.
2. The applicant must sign this form in the presence of a notary public other than the applicant.
3. In compliance with the Federal Privacy Act of 1974, the disclosure of the social security number on this form is voluntary. It is not disclosed to
the public. The number is used by the Secretary of State to maintain accurate notary files. Therefore, while voluntary disclosure is requested,
failure to do so will not invalidate this notary bond.
TYPE OR PRINT LEGIBLY For reference, see North Dakota Century Code Chapter 44-06.1.
Applicant’s name Applicant’s social security number

Applicant’s home mailing address City State ZIP code

Surety company’s name Surety company’s telephone number

Surety company’s address City State ZIP code

Attorney-in-Fact Signature and Printed Name Date

ACKNOWLEDGMENT OF PRINCIPAL (APPLICANT)

I, the undersigned principal (applicant), do hereby hold and firmly bind myself
unto the people of the state of North Dakota in the penal sum of SEVEN
THOUSAND FIVE HUNDRED DOLLARS for the payment of which I bind
myself, my heirs, executors, administrators and assigns, firmly by these
presents. The condition of the foregoing obligation is for my appointment as a
notary public within and for the state of North Dakota. If I perform the duties of
notary public according to the law, then this obligation becomes null and void;
otherwise, it remains in full force and effect.

Applicant signature Date

State County

The foregoing instrument was Date
acknowledged before me on
Signature of notary public or other authorized officer

Commission expiration date (only if not listed on stamp)

Notary Stamp
—————————————————–
NOTARY APPLICATION For Office Use Only
SECRETARY OF STATE ID Number:
SFN 11001 (07-2017) WO Number:
Filed: By:

Expiration Date:
Secretary of State
State of North Dakota
600 E Boulevard Ave Dept 108
TYPE OR PRINT LEGIBLY Bismarck ND 58505-0500
Telephone: (701) 328-2901
SEE INSTRUCTIONS FOR FEE, FILING, AND MAILING INFORMATION. Toll-Free: (800) 352-0867, option 7
Website: sos.nd.gov
For reference, see North Dakota Century Code Chapter 44-06.1.
1. Prefix 2. Applicant’s name (REVIEW INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING) 3. Social security number
Mr. Ms.
4. Home mailing address City State ZIP code

5. Work mailing address City State ZIP code

6. Home telephone number 7. Work telephone number 8. Email address

9. Spouse’s complete name (if applicable) 10. If not a North Dakota resident, list the county and state of residence, or the
North Dakota city where the applicant works (as applicable)

11. Type of application 12. Previous expiration date (if applicable)
New commission Renewal of commission
13. ALL applicants must answer the following questions. If “yes,” attach a written explanation and ALL legal documentation, if applicable.
YES NO
Have you ever been the subject of any inquiry or investigation by any agency of the state of North Dakota
Has any occupational license held by you in any state (including North Dakota) been censured, suspended, revoked, cancelled, or
terminated; or have you been subject to any type of administrative action in any state (including North Dakota)

Have you ever been convicted of, or entered a guilty plea to, any criminal offense (felony, misdemeanor, or infraction) other than traffic
violations, in any city, state, or federal court
Have you ever been a defendant in any lawsuit involving claims of fraud, misrepresentation, coercion, mismanagement of funds, breach of
fiduciary duty, or breach of contract
AFFIDAVIT OF QUALIFICATIONS
I, the undersigned, being first duly sworn, hereby state that I am over the age of 18; a citizen or permanent resident of the United States; and a North Dakota
resident, am employed in North Dakota, or reside in a county that borders North Dakota and which is in a state that extends reciprocity to a notary public who
resides in a bordering county of North Dakota; and I desire to become a commissioned notary public in the state of North Dakota.

OATH OF OFFICE
I do solemnly swear (or affirm) that I will support the Constitution of the United States and the Constitution
of the State of North Dakota; and that I will faithfully discharge the duties of the office of notary public
according to the best of my ability, so help me God (or under pains and penalties of perjury).

14. Signature (sign exactly as provided in box 2 above – this will be the manner in which you will sign your name ATTENTION: MUST BE SIGNED IN
when performing notarial acts)
THE PRESENCE OF A NOTARY!

State County Notary Stamp

Signed and sworn to (or Date
affirmed) before me on
Signature of notary public or other authorized officer

Commission expiration date (only if not listed on stamp)

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:
$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

$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 (1/05)
—————————————————–

ISSUED BY: POLICY NO:
ISSUED TO:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION/NONRENEWAL – MISSISSIPPI
FULL CANCELLATION – INSURER

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 any reason by mailing or delivering to the entity named in Item 1 of the Declarations written
notice of cancellation at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or
(2) 30 days before the effective date of cancellation if we cancel for any other reason.

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 10 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 if we are nonrenewing for nonpayment of premium or at least 30 days before
such date if we are nonrenewing for any other reason.

3. Proof of mailing constitutes 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-5048 (06-04)
—————————————————–

ISSUED BY: POLICY NO:
ISSUED TO:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION/NONRENEWAL – MISSISSIPPI
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 10 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 if we are nonrenewing for nonpayment of premium or at least 30 days before
such date if we are nonrenewing for any other reason.

3. Proof of mailing constitutes 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-5049 (06-04)