Payment Form

Payment Form (Revised 06/16) Date of Receipt (for office use). Please select requested processing: Expedited Handling (not available for Authentication Services or Trademark Applications) ($25 per corporate document/$10 for copies/ $15 for UCC) Regular Handling SUBMITTER INFORMATION: Company/Firm or Individual Name: Street: City/State/Zip: Phone: Email: DOCUMENT FILING INFORMATION: Name listed on document: File # (if applicable): Type of Document: Number of Pages: PAYMENT INFORMATION: Visa Mastercard Discover American Express Card #: Exp (MM/YY): Security Code: Name on Card: Billing Address: City/State: Zip Code: Signature: RETURN TO: Name: Street: City/State/Zip: Phone: Email: Same as submitter INSTRUCTIONS: Mark the appropriate handling request. If expedited include an email address. Submitter Information: Completely fill out information of the person/company submitting the documents. Document Filing Information: Completely fill out information regarding the document that is being submitted. Payment Information: Check the box with your method of payment. Include the necessary information. For Mastercard, Visa, and Discover, the Security Code is the last three digits in the signature area on the back of your card. For American Express, it is the four digits on the front of the card. Fees paid by credit card are subject to a statutorily authorized convenience fee of 2.7% of the total fees incurred. Return To: Include a return address to which the documents should be returned. If same as submitter, check the box. Check/Money Order Enclosed (no electronic check) Client Account Account #: Name on Account: LegalEase Account #: 500679 Client Reference #: - Fax: American LegalNet, Inc. www.FormsWorkFlow.com