Fillable Printable Payment Form Date of Receipt

Payment Form Date of Receipt

Date of Receipt (for office use).

– – –

Payment Form

(Revised 08/14)

Please type or print clearly.

(Expedited Handling Service is only available for Business Entity Filings.)

Expedited Handling Requested? Yes No

($25 per document/$10 for copies/certificates)

Fax:

(required for expedited filings)

PAYMENT

Charge to Credit Card

Card Type: American Express Discover MasterCard Visa

Card No.:

Exp: (MM/YY) *Security Code:

Name on Card: Phone:

Credit Card Billing Address:

City: State: Zip Code:

Charge to Secretary of State Client Account No.:

(filings require sufficient funds in client account)

Name on Account:

Charge to LegalEase Account No.:

500679

(For Information about LegalEase, call 800-253-5749)

Client Reference No.: Case No.:

Fees paid by credit card are subject to a statutorily authorized convenience fee of 2.7% of the total fees incurred.

Signature: Date:

DOCUMENT TO BE FILED OR REQUEST FOR COPIES/CERTIFICATE

(include name on document and SOS file number if applicable)

REQUESTOR NAME & ADDRESS (IF DIFFERENT THAN PAYMENT INFORMATION)

Do not complete this section if requesting Authentication Services

Name:

Street:

City: State: Zip Code:

Phone:

* For Mastercard, Visa, and Discover, the Security Code is the last three digits in the signature area on the back of your card.

For American Express, it is the four digits on the front of the card.