Payment Form                                                                                  Date of Receipt (for office use).  
(Revised 03/32  )                                                                              

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