Texas State Notary Bureau |Texas Notary Training, Support and Supplies

STATEMENT OF OFFICER
(Pursuant to Art. XVI, Section 1(b), Texas Constitution)

I, _________________________________________________ do solemnly swear (or affirm), that I have not directly or indirectly paid,
                 (Applicant's Name)
offered, promised to pay, contributed, or promised to contribute any money, or thing of value, or promised any public office or
employment for the giving or withholding of a vote at the election at which I was elected or as a reward to secure my appointment
or confirmation, whichever the case may be, so help me God.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING STATEMENT AND THAT THE FACTS STATED
THEREIN ARE TRUE.
__________________    Date   X__________________________________
Affiant's Signature

Take the Official Bond form below to any insurance agency or bonding company for completion, unless it is preprinted with the name and address of an
insurance agency/surety company. If it is so preprinted, return it to the agency specified on the bond for completion. DO NOTALTER THE BOND IN
ANY MANNER. Only a bond written on a company licensed in Texas to issue fidelity and surety bonds will be accepted. A premium will be collected by
the insurance/surety company from which you purchase the surety bond. The Texas Department of Insurance does not have a standard premium rate for this
bond limit; thus, you must check with the insurance/surety company for the approved premium rate.

OFFICIAL NOTARY PUBLIC BOND FOR THE STATE OF TEXAS

STATE OF TEXAS
COUNTY OF TRAVIS
KNOW ALL PERSONS BY THESE PRESENTS: THAT WE _________________________________________________,
                                                                                                                                       (Applicant's Name)

AS PRINCIPAL AND WESTERN SURETY COMPANY, A CORPORATION DULY LICENSED TO DO BUSINESS IN THE STATE OF TEXAS, AS
SURETY ARE HELD AND FIRMLY BOUND UNTO THE GOVERNOR OF THE STATE OF TEXAS AND TO HIS/HER SUCCESSORS IN OFFICE,
IN THE SUM OF TEN THOUSAND DOLLARS ($10,000) FOR THE PAYMENT OF WHICH, WELL AND TRULY TO BE MADE WE BIND OURSELVES,
OUR HEIRS, EXECUTORS AND ADMINISTRATORS JOINTLY AND SEVERALLY BY THESE PRESENTS.
THE CONDITION OF THIS BOND IS SUCH THAT THE ABOVE NAMED PRINCIPAL HAS BEEN APPOINTED A NOTARY PUBLIC FOR THE STATE
OF TEXAS SHALL FAITHFULLY PERFORM THE DUTIES OF SAID OFFICE OF NOTARY PUBLIC, THEN THIS SHALL BECOME NULL AND VOID,
OTHERWISE IT SHALL REMAIN IN FULL FORCE AND EFFECT.

WITNESS OUR HANDS ON THIS _______ DAY OF _________________ 20______
     WESTERN SURETY COMPANY___
INSURANCE OR BONDING COMPANY

BY______________________________________________
SIGNATURE OF SURETY OFFICER OR ATTORNEY IN FACT
   x_{___________________________________}
            SIGNATURE OF PRINCIPAL (APPLICANT)
NOTARY INSURANCE SERVICES, INC.
                         AGENCY NAME
4107 SOUTH 1st STREET, AUSTIN, TEXAS 78745
                         AGENCY ADDRESS

                                                                                             INSTRUCTIONS
Complete both sides of this form using black ink or a typewriter. THIS FORM MUST BE ONE PAGE, FRONT AND BACK (8 1/2 x 11).
RENEWALS: Same procedure and fee as required for obtaining original commission. A Notary Public may be reappointed upon
submission of a new application not earlier than ninety (90) days prior to the expiration of the Notary Public's term. A Notary Public who
is not reappointed on or before the expiration date of the term the notary public is serving will be appointed for a new term expiring four
years from the date of qualification.
COSTS TO BE A TEXAS NOTARY PUBLIC: Secretary of State fees $21.00, applicable premium payable to the insurance/surety
company from which you purchase a $10,000 surety bond; and the costs of purchasing a personalized notary seal and record book (available from this Notary Supplier).
Return this completed form, order and payment to: NOTARY INSURANCE SERVICES, INC., 4107 South 1st Street, Austin, Texas 78745

STATEMENT OF OFFICER (Pursuant to Art. XVI, Section 1(b), Texas Constitution)

I, _________________________________________________ do solemnly swear (or affirm), that I have not directly or indirectly paid, (Applicant's Name) offered, promised to pay, contributed, or promised to contribute any money, or thing of value, or promised any public office or employment for the giving or withholding of a vote at the election at which I was elected or as a reward to secure my appointment or confirmation, whichever the case may be, so help me God. UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING STATEMENT AND THAT THE FACTS STATED THEREIN ARE TRUE.

__________________ Date	X__________________________________ Affiant's Signature

STATE OF TEXAS
COUNTY OF TRAVIS
KNOW ALL PERSONS BY THESE PRESENTS: THAT WE _________________________________________________, (Applicant's Name)
AS PRINCIPAL AND WESTERN SURETY COMPANY, A CORPORATION DULY LICENSED TO DO BUSINESS IN THE STATE OF TEXAS, AS SURETY ARE HELD AND FIRMLY BOUND UNTO THE GOVERNOR OF THE STATE OF TEXAS AND TO HIS/HER SUCCESSORS IN OFFICE, IN THE SUM OF TEN THOUSAND DOLLARS ($10,000) FOR THE PAYMENT OF WHICH, WELL AND TRULY TO BE MADE WE BIND OURSELVES, OUR HEIRS, EXECUTORS AND ADMINISTRATORS JOINTLY AND SEVERALLY BY THESE PRESENTS. THE CONDITION OF THIS BOND IS SUCH THAT THE ABOVE NAMED PRINCIPAL HAS BEEN APPOINTED A NOTARY PUBLIC FOR THE STATE OF TEXAS SHALL FAITHFULLY PERFORM THE DUTIES OF SAID OFFICE OF NOTARY PUBLIC, THEN THIS SHALL BECOME NULL AND VOID, OTHERWISE IT SHALL REMAIN IN FULL FORCE AND EFFECT.
	WITNESS OUR HANDS ON THIS _______ DAY OF _________________ 20______
WESTERN SURETY COMPANY___ INSURANCE OR BONDING COMPANY BY______________________________________________ SIGNATURE OF SURETY OFFICER OR ATTORNEY IN FACT		x_{___________________________________} SIGNATURE OF PRINCIPAL (APPLICANT)
NOTARY INSURANCE SERVICES, INC. AGENCY NAME 4107 SOUTH 1st STREET, AUSTIN, TEXAS 78745 AGENCY ADDRESS
INSTRUCTIONS
Complete both sides of this form using black ink or a typewriter. THIS FORM MUST BE ONE PAGE, FRONT AND BACK (8 1/2 x 11). RENEWALS: Same procedure and fee as required for obtaining original commission. A Notary Public may be reappointed upon submission of a new application not earlier than ninety (90) days prior to the expiration of the Notary Public's term. A Notary Public who is not reappointed on or before the expiration date of the term the notary public is serving will be appointed for a new term expiring four years from the date of qualification. COSTS TO BE A TEXAS NOTARY PUBLIC: Secretary of State fees $21.00, applicable premium payable to the insurance/surety company from which you purchase a $10,000 surety bond; and the costs of purchasing a personalized notary seal and record book (available from this Notary Supplier). Return this completed form, order and payment to: NOTARY INSURANCE SERVICES, INC., 4107 South 1st Street, Austin, Texas 78745