The Department of State’s Uniform Commercial Code Unit accepts Mastercard, Visa and American Express for the payment of UCC filing processing
fees and search request fees. The use of credit cards is not acceptable for copy request fees. To pay for a fee using your credit card, complete and sign
this form and submit it with your UCC filing or search request.
THE NAME OF THE DEBTOR TO WHICH THIS REQUEST APPLIES IS:
Name:
Contact Name:
Daytime Telephone Number:
( ) - ___ ___ ___ - ___ ___ ___ ___ Total Amount Due: $
PLEASE INDICATE TRANSACTION TYPE:
UCC Filing
UCC Search Deposit to Drawdown Account
ACCOUNT #
PLEASE INDICATE LEVEL OF SERVICE:
Please refer to the fee schedule for specific processing and search request fees.
Requests for expedited service must be received prior to 2:30 p.m.
Routine 24-48 Hours
Expedite - Same Day $75 in addition to filing and/or search fees.
CARDHOLDER’S INFORMATION:
Please type or print all information clearly. Unclear or illegible information may result in
rejection of your UCC filing or search request.
Credit Card:
MasterCard
Visa American Express
Credit Card Number: — — —
Expiration Date: Month: Year:
CARDHOLDER’S NAME (PRINT)
CARDHOLDER’S BILLING ADDRESS AS LISTED WITH CREDIT CARD COMPANY
CITY
STATE
ZIP CODE
Cardholder’s Signature Date
DOS-0985-f (07/16) Page 1 of 1
F O R F I L I N G O F F I C E U S E O N L Y
Authorization Number: Cash Number:
Date:
Initials:
Transaction Number(s):
