Secretary of State Payment Form
|Payment Form | |Date of Receipt (for office use). |
|(Revised 10/22) | | |
| |
|Please select requested processing: |
| |
| |Expedited Handling (not available for Authentication Services, Notary Applications, or Trademark Applications) |
| | |($25 per corporate document/$10 for copies/$15 for UCC) |
| |Regular Handling |
| |
| |INSTRUCTIONS: |
| |Mark the appropriate handling request. |
| |If expedited include an email address. |
| |Submitter Information: Completely fill out information of the |
| |person/company submitting the documents. |
| |Document Filing Information: Completely fill out information regarding |
| |the document that is being submitted. |
| |Payment Information: Check the box with your method of payment. Include |
| |the necessary information. 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. Fees paid by credit card are subject to a statutorily |
| |authorized convenience fee of 2.7% of the total fees incurred. |
| |Return To: Include a return address to which the documents should be |
| |returned. If same as submitter, check the box. |
|SUBMITTER INFORMATION: | |
| | |
|Company/Firm or Individual | | | |
|Name: | | | |
|Street: | | | |
|City/State/Zip: | | | |
|Phone: | |Fax: | | | |
|Email: | | | |
| | |
| | |
|DOCUMENT FILING INFORMATION: | |
| | |
|Name listed on document: | | | |
|File # (if applicable): | | | |
|Type of Document: | | | |
|Number of Pages: | | | |
| | |
| | | | |
|PAYMENT INFORMATION: |
|Visa | Mastercard | Discover | American Express | Check/Money Order Enclosed (no electronic check) |
|Card #: | - - - |
|Exp (MM/YY): | | |Security Code: | | | Client Account |
|Name on Card: | | |Account #: | |
|Billing Address: | | |Name on Account: | |
|City/State: | | | |
|Zip Code: | | | LegalEase |
|Signature: | | |Account #: |500679 - | - - |
| | | |Client Reference #: | |
| | | | |
| | | | |
|RETURN TO: | Same as submitter |
|Name: | |
|Street: | |
|City/State/Zip: | |
|Phone: | | |Fax: | |
|Email: | |
| | |
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