Short Certificate Request

SHORT CERTIFICATE REQUEST Short Certificates, for Decedent Estates on file in Chester County, are $10.00 each. The fee is payable by credit card, check or money order, payable to Register of Wills. Do Not Mail Cash. Please send a self-addressed stamped envelope. To request Short Certificates, please provide the following information: PRINT OR TYPE CAREFULLY Full Name of Decedent: ____________________________________________________________ Chester County File Number: _______________________________________________________ If not available, contact the office at 610-344-6335 (Press 3) to obtain the file number. Date of Death: ______________________ Number of Short Certificates: __________ Date this request sent: _______________________ Amount Enclosed: ___________________________ ($10.00 each) Name and Mailing Address: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Please provide a contact Phone Number: ______________________________ Mail this request with a self-addressed stamped envelope to the address below with a check or money order payable to Register of Wills. If paying with a credit card fill out all of the information below. Register of Wills Chester County Justice Center 201 W. Market Street, Suite 2200 P.O. Box 2746 West Chester, PA 19380-0989 Credit Card Information *Please note this office will ONLY accept payments from MasterCard, Discover, American Express and Visa. In addition to the cost of the office fee the payment processing company will charge a separate convenience fee of 2.25% of the total amount paid or a $2.00 minimum. Provide email for a receipt. Name on Card:________________________________ Credit Card Holder's Address:_______________________________________ _______________________________________ Credit Card Number:______________________________________________ Expiration Date:________________________ Security Code:____________ Signature:______________________________________________________ E-mail Address:__________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com