State of South Dakota

Notary Public Application, Oath & Bond
Filing Fee: $30.00 (Must be included to file)

Submit to: Secretary of State, 500 East Capitol Ave, Pierre, SD 57501
Type or print neatly – please read instructions and complete all sections.
MAKE IMPRINT OF SEAL HERE TO THE SECRETARY OF STATE OF SOUTH DAKOTA: I hereby respectfully apply
(Imprint required for processing) to be commissioned as a Notary Public for the State of South Dakota.
NAME
(print your name EXACTLY as found on your seal imprint)
RESIDENCE ADDRESS

CITY _______________________________________ STATE _______ ZIP ______________
MAILING ADDRESS
CITY _______________________________________ STATE _______ ZIP ______________
COUNTY
PHONE ___________________ EMAIL (Optional) _______________________________

Complete the following if you reside in an out-of-state county bordering South Dakota:

Employer/Business Name
South Dakota Business Address:
Street City State Zip
Have you ever been a SD Notary Public Yes No If yes, when did/does your commission expire
What name(s) was your commission under ____________________________________________________________________
Date of Birth Have you ever been convicted of a felony

STATE OF SOUTH DAKOTA OATH (MUST be completed and signed)
COUNTY OF
I, (enter your name EXACTLY as found on your seal imprint), being first
duly sworn, depose and state that the answers to the questions on this application are true and complete to the best of my
knowledge and that I am of legal age and meet the state residency requirements of SDCL 18-1-1. I do solemnly swear that I
will support the Constitution of the United States and the Constitution of the State of South Dakota and that I will faithfully and
impartially perform the duties of a NOTARY PUBLIC within and for the State of South Dakota according to the law and to the
best of my ability, so help me God.
Dated this day of , _______ _____________________________________________________
(Applicant Signature – sign name EXACTLY as found on your seal imprint)

(Entire section must be completed for a Bond) BOND
Bond No. _____________________________
(If a Personal Surety is being used, omit the following and complete the Personal Surety form on the backside)

We , as principal, and ___________________________________
(name of notary applicant EXACTLY as found on your seal) (name of surety company)
are bound to the State of South Dakota in the penal sum of $5000.00 for payment of which we bind ourselves, our successors,
or representatives, executors, and administrators jointly and severally hereby. This obligation is conditioned upon appointment
and commission as a Notary Public of the above-named Principal by the Secretary of State and covers the official term of six (6)
years from the date of appointment. If the Principal performs well and faithfully all of the duties of the office of Notary Public
according to the laws of South Dakota, then the above obligation is to be null and void, otherwise, it is to remain in effect.
Dated this day of _______________________________________________
(Applicant Signature EXACTLY as found on your seal imprint)
(Both Signatures Required) _______________________________________________
(Surety’s Signature)

FOR INTERNAL OFFICE USE ONLY
Approved by the
South Dakota Receipt No: ____________________ Commission Date: _______________
Attorney General _______________
File Date: ______________________ Notary ID: ______________________

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

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)