Payment Form
(Revised 11/11)
Please type or print clearly.
Date of Receipt (for office use).
Expedited Handling Requested? Yes No
($25 per document; not available for Apostilles, Service of Process, Trademarks, and some other filings)
SHIP TO
Name:
Street:
City: State: Zip Code:
Phone: Fax:
(required for expedited filings)
DOCUMENT TO BE FILED OR REQUEST FOR COPIES/CERTIFICATE
(include name on document and SOS file number if applicable)
PAYMENT
Charge to Credit Card
Card Type: American Express Discover MasterCard Visa
Card No.: – – – Expires:
(mm/yy)
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
– – –
Client Reference No.: Case No.:
Fees are calculated based on the secretary of state fee schedule. Fees paid by credit card are subject to a statutorily
authorized convenience fee of 2.7% of the total fees incurred.
Signature: Date:
Batch No.:
(for office use)
