Attach this form to your document, certificate or other written request.
The Name of the Corporation or Business Entity to Which This Request Applies is:
Check Box for Requested Service: Fill in Fee or Amount:
FILING OF DOCUMENT OR CERTIFICATE (Consult appropriate fee schedule for fee) $ _________________
Check the appropriate box: Routine Processing: No additional fee
Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee
$ _________________
CERTIFIED COPY (The fee for each certified copy is $10) $ _________________
Check the appropriate box: Routine Processing: No additional fee
Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee
$ _________________
PLAIN COPY (The fee for each plain copy is $5) $ _________________
Check the appropriate box: Routine Processing: No additional fee
Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee
$ _________________
CERTIFICATE OF STATUS (Certificates of Good Standing, etc. The fee for each certificate is $25.) $ _________________
Check the appropriate box: Routine Processing: No additional fee
Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee
$ _________________
SERVICE OF PROCESS (Must be served in person at the above address) $ _________________
BIENNIAL / FIVE YEAR STATEMENT $ _________________
OTHER $ _________________
DEPOSIT TO DRAWDOWN :
Account Name: Account Number: $ _________________
TOTAL (Total Amount Due) $ _________________
Same Day expedited service requests must be received by 12 noon on regular business days.
2-hour expedited service requests must be received by 2:30 p.m. on regular business days.
Expedited processing fees are charged even if a document, certificate or other request is rejected as deficient.
Credit/Debit Card Information: MasterCard Visa American Express
TYPE OR PRINT CLEARLY
Card Number: ______________________________________________________ Expiration Date (Month/Year): ________________
Name as it Appears
on Card:
Cardholder’s Billing Address:
City: _______________________________________________ State: Zip Code: ______________________
Fax Number:
Cardholder’s Signature: Date:
If the name on the card is in the name of a corporation or
other business entity, please print the signer’s name:
DOS-1515-f (Rev. 04/16) Page 1 of 1
