Request For Authentications Service {DS-4194}

U.S. Department of State REQUEST FOR AUTHENTICATIONS SERVICE SECTION 1: CUSTOMER CONTACT INFORMATION Name (Last, First, MI) Suffix/Prefix E-mail Home Phone Extension Cell Phone Extension Work Phone Extension Case Type (If Federal Agency Must Be Official Business) Specify Country Formal Mailing Address Line 1 Line 2 City State ZIP Code SECTION 2: COURIER/REPRESENTATIVE CONTACT INFORMATION Are you submitting/retrieving this request on behalf of another individual? Name (Last, First, MI) Company Phone Number Extension SECTION 3: SHIPPING DETAILS (FOR MAILED IN REQUESTS ONLY) Delivery Method Tracking Number Shipping Address Same address as above Country Shipping Address Line 1 Line 2 City State ZIP Code Specify SECTION 4: DOCUMENT INFORMATION (CONTINUED ON NEXT PAGE) Country Number of Documents Document Type Document Label (Official Use Only) SECTION 5: PROJECTED COST Total Number of Documents Estimated Cost DS-4194 02-2012 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Name (Last, First, MI) Suffix/Prefix E-mail SECTION 4: ADDITIONAL DOCUMENTS (CONTINUED) Country Number of Documents Document Type Document Label (Official Use Only) DS-4194 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com U.S. Department of State REQUEST FOR AUTHENTICATIONS SERVICE INSTRUCTIONS PURPOSE Form DS-4194 is used by the U. S. Department of State for documents submitted by U.S. citizens and foreign nationals. The Authentications Office is responsible for signing and issuing certificates under the Seal of the U. S. Department of State for documents being submitted to foreign countries. INSTRUCTIONS Complete one copy of this form for yourself or your company to be submitted with your documents and payment. You must submit a new cover letter for each request. Failure to do so will result in your case being rejected and documents being returned. WARNING Any false statement or concealment of a material fact may result in a delay or un-authenticated documentation. FORM DS-4194 SECTION 1: REQUESTOR'S CONTACT INFORMATION Provide individual's full name or company's name (complete spelling). Indicate e-mail address; telephone number(s) home, work and/or cell. If the document(s) were mailed or hand carried for a Federal Agency for Official Government business please indicate agency name, bureau and/or office acronyms. Provide formal mailing address (include street address, city or town, zip code, province or country). SECTION 2: SUBMITTER'S CONTACT INFORMATION If you are submitting/or retrieving a request on behalf of someone other than yourself or a company, please provide specific and detailed information. The full name of the individual's or company's name is required to properly search the database. If you are retrieving document(s) your name must appear in section 2 of the intake form and State issued identification is required. Provide individual's full name or company's name (complete spelling). Indicate e-mail address; telephone number(s) day time, evening or cell number. SECTION 3: METHOD OF RETURN (MAIL-IN) Indicate delivery method (type of mail service used to return the document). If this information is available, provide a tracking number and include all letters and numbers (i.e., DOS, USPS, FED/EX, UPS, DHL & Others). Indicate the complete address that the document (s) will be returned to for proper delivery. It is imperative that the complete address is entered accurately! (i.e., street address, city, state, ZIP code & country). REVIEW INFORMATION FOR ACCURACY! Please note: All documents submitted will be returned to one location. SECTION 4: DOCUMENT INFORMATION Indicate the country (or countries) of use, the number of documents, and the document type. (A maximum of 15 documents are allowed per customer/company person for walk-in services). SECTION 5: METHOD OF PAYMENT Please note: The authentication processing fee is $8.00 per document, not per page. This fee will be charged regardless of whether you receive an authentication certification or a correspondence letter. This change in policy will take effect on April 1, 2012. Please pay the total amount shown in the estimated cost field. (The exact amount is required.) Allowable payment methods include U.S. Postal Money Orders, checks (personal, corporate, certified, cashiers, travelers) all payable to "U.S. Department of State." Walk-in service only: In addition to the payment methods noted above; Credit Cards and Debit/Check Cards (VISA, MasterCard, American Express, Discover) are accepted. DS-4194 02-2012 Instructions Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com