Prepaid Account Debit Form Deliver to: Colorado Secretary of State 1700 Broadway, Suite 200 Denver, CO 80290 ABOVE SPACE FOR OFFICE USE ONLY The Prepaid Account Holder identified below instructs the Colorado Secretary of State to debit their Prepaid Account as stated below in the amount indicated for payment of the fee(s). 1. The Account Holder’s name, account number and mailing address are: Name ______________________________________________________ Account number ______________________________________________________ Mailing address ______________________________________________________ (Street number and name) ______________________________________________________ __________________________ ____ ____________________ (City) (State) (Postal/Zip Code) _______________________ ______________. (Province – if applicable) (Country – if not US) 2. The Contact Person’s name and telephone number are: Name ______________________________________________________ Telephone number ______________________________________________________. 3. Describe transaction ____________________________________________________________________. (examples: “file Articles of Incorporation for ABC Corp” or “file a UCC-1 for Smith as debtor”) 4. The amount of the Fee to be debited is $ _____________________________________________________. 5. (Optional) Expedited Service Mark the box if the Expedited Service function is available for this transaction and is requested. The additional Expedited Service Fee will be debited from this account. (The Expedited Service Fee can be found on the online Fee Schedule.) 6. (Optional) The Account holder’s Job Number for this transaction is ______________________________. (A Job Number may consist of twelve characters, alpha and/or numeric. It will appear next to this transaction on the monthly statement issued for this Prepaid Account.) 7. (Optional) Account Holder’s additional information pertaining to this transaction ______________________________________________________________________________________ ______________________________________________________________________________________. (This information is for the use of the Account Holder only. It will not appear on the monthly statement issued for this Prepaid Account.) Rev. 7/31/2008 American LegalNet, Inc. www.FormsWorkflow.com