North Carolina > Workers Comp
Certification Of Payment Of Processing Fee For Form 24 Application - North Carolina
| Certification Of Payment Of Processing Fee For Form 24 Application Form. This is a North Carolina form and can be used in Workers Comp . |
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I.C. No.__________, _________________, Employee, Plaintiff, v. __________________________, Employer, and _________________, Carrier, Defendants. CERTIFICATION OF PAYMENT OF PROCESSING FEE FOR FORM 24 APPLICATION I hereby certify and attest that payment in the amount of $______________________________ has been sent by _________________________________ on __________________________ (U.S. Mail or other method of delivery) (date) by _______________________________________________ by Check # _________________ (person or entity sending payment) as the processing fee for the Form 24 Application to the North Carolina Industrial Commission. This the ____________ day of _____________, __________. ______________________________________________________________________________ Signature of Certifier ______________________________________________________________________________ Print Name Title of Certifier: _______________________________________________________________ (attorney/adjuster/other) E-Mail address of Certifier: ______________________________________________________ Other address information of Certifier: ______________________________________________ Fax information of Certifier: ______________________________________________________ Telephone number of Certifier: ____________________________________________________ *This certification is required for Form 24 Applications that are sent by e-mail submission. American LegalNet, Inc. www.FormsWorkFlow.com
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