Daytime telephone number: Fax number:
Card Number:
NYS Department of State
DIVISION OF CORPORATIONS
Credit Card/Debit Card Authorization
One Commerce Plaza, 99 Washington Ave.
Albany, NY 12231-0001
www.dos.state.ny.us
Attach this form to your document or written request.
The Department of State’s Division of Corporations accepts MasterCard, Visa, American Express and Diners Club for payment of certain fees.
Name of Corporation or Other Business Entity To Which This Service Request Applies:
Check Box for Requested Service: Fill in Fee or Amount:
G
FILING OF DOCUMENTS AND CERTIFICATES
(Please consult the appropriate fee schedule for specific filing fees) $
*Optional Expedited Service:
G
24 hour-$25
G
Same day-$75
G
2 hour-$150 $
G
CERTIFIED COPY
($10 each) $
*Optional Expedited Service:
G
24 hour-$25
G
Same day-$75
G
2 hour-$150 $
G
PLAIN COPY
($5 each) $
*Optional Expedited Service:
G
24 hour-$25
G
Same day-$75
G
2 hour-$150 $
G
CERTIFICATE UNDER SEAL
(Certificates of Good Standing, etc. ($25 each) $
*Optional Expedited Service:
G
24 hour-$25
G
Same day-$75
G
2 hour-$150 $
G
SERVICE OF PROCESS
(Must be served in person at the above address) $
G
BIENNIAL/FIVE YEAR STATEMENT
$
G
OTHER
$
G
DEPOSIT TO DRAWDOWN
$
Account Name:
Account Number:
TOTAL (Total Amount due) $
* Same day expedited service requests must be received by 12 noon.
2 hour expedited service requests must be received by 2:30 p.m.
Expedited service fees are non-refundable and will not be refunded if a filing is rejected.
MasterCard
Q
Visa
Q
American Express
Q
Diners Club
Q
Expiration Date: (Month and Year)
Name as it Appears on the Credit Card or Debit Card (Print)
Cardholder’s Billing Address as Listed with Credit Card or Debit Card Company
City State Zip Code+4
Cardholder’s Signature
Date
If the name on the credit card or debit card is in the name of a corporation or other business entity, please print the signer’s name:
DOS-1515 (Rev. 4/08)
