Date of Receipt (for office use).
Payment Form
(Revised 06/16)
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.
Method of Return: Include a return address to which the
documents should be returned. If same as submitter,
check the box.
Please select requested processing:
Expedited Handling (not available for Authentication Services or Trademark Applications)
($25 per document/$10 for copies/ $15 for UCC)
Regular Handling
SUBMITTER’S INFORMATION:
Company/Firm or
Individual Name:
Street:
City/State/Zip:
Phone:
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:
Name on Card:
Billing Address:
City/State:
Zip Code:
Signature:
Client Account
Account #:
Name on Account:
LegalEase
-Account #: 500679 -
Client
Reference #:
RETURN TO:
Same as submitter
Name:
Street:
City/State/Zip:
Phone: Fax:
Email:
(for expedited handling only)
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