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*230105* BARBARA K. CEGAVSKE Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684-5708 Website: www.nvsos.gov ePayment Checklist (For Counter, Fax and Mail Requests) USE BLACK INK ONLY - DO NOT HIGHLIGHT Service Type: Counter Mail Fax (Expedite Processing Requires Additional Fees) Order Processing Requested: Regular Processing 24-HOUR Expedite 2-HOUR Expedite 1-HOUR Expedite Payment by Card Card Type: VISA (card holder name and billing address required below) MasterCard Discover American Express V CODE* Customer Credit Card Number: * 3-digit number found on the far right of the backside of VISA, MasterCard and Discover cards 4-digit number found on the front right side of American Express card. NOTICE: For security and verification purposes, all credit card payments must include the 3 or 4-digit CVV2 code (VCode) number located on the credit card. Failure to include this code will result in the rejection of your filing or service request. Credit Card Expiration Date: Month Year Amount to Charge Card: USD $ Order Information (required) Entity Name/Order Reference: Card Holder Information: Name as it Appears on the Account Billing Address City, State, Zip Telephone Payment Authorization I authorize the Secretary of State to bill an amount not to exceed the following to be charged to the above listed account(s): X Authorized Signature Not to Exceed Amount: USD $ American LegalNet, Inc. www.FormsWorkFlow.com Nevada Secretary of State ePayment Checklist Revised: 1-5-15