TOTAL CHARGES:
$_____________
County Clerk Credit Card Payment Form
Date: / /
Name: ____________________________________________________
Business (optional): ___________________________________________
Phone number: (____ ) _____- _________ Fax: (____) ______-_______
Email: ____________________________________________________
Authorized Signature: ________________________________________
This form authorizes the merchant (Vi
talChek) to charge my credit card, for services rendered by the County Clerk's office, plus a $2.50
service fee. A base percentage of 4% will be charged on credit transactions over $50.00. Please see our website for additional fees.
Address to send document/s: _______________________________________
_______________________________________
_______________________________________
***********************************************************************
* (Check which applies) Master Card Discover ____
American Express ____ Visa _____
*Name as it appears on Card: ____________________________________________
Credit Card Account Number: _--___ ______ -- --
CVV# ___ ___ ___ (security code on back of card) *Exp. Date: / (MM/YY)
Billing Address: ______________________ City __________________ ZIP___________
**Note**
The ZIP Code
must
match the cardholder’s billing address; if not, the transaction will
be declined
.
*************************************************************************
Prices:
• Birth Certificate: $23.00 each + credit card transaction fee
• Death Certificate: $21.00 for first copy, $4.00 for each additional copy requested at same time +
credit card transaction fee
•
Assumed Name/Abandonment of Assumed Name: $24.00
(application must be notarized)
+ $0.50
per additional name + credit card transaction fee
•
Real Property Recording: $26.00 for first page + $4.00 Recording Page + $4.00 each additional
page (
if applicable
) + credit card transaction fee
o
Other fees may apply depending on document type. Please see our website for additional
fees.
click to sign
signature
click to edit
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