Deliver to: Colorado Secretary of State 1700 Broadway, Suite 200 Denver, CO 80290 (303) 894-2200 ABOVE SPACE FOR OFFICE USE ONLY Prepaid Account Debit Form 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). Prepaid Account Number The total amount to be debited is $ (Optional) Expedited Service ͙ Mark the box if Expedited Service is available and requested for this transaction. An additional service fee will apply. Fees can be found on the online Fee Schedule at www.sos.state.co.us. Describe transaction: (example: "file Statement of Foreign Entity Authority for ABC Corp") The Account Holder’s name and address are Business/Entity Name Business/Entity Address (Number and Street Name) (City) (State) (ZIP/Postal Code) (Province and Country, if applicable) Authorized Individual (Name) (Title) (Telephone Number, with Area Code) (Fax Number, with Area Code) (E-mail address) (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.) (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.) (Signature of Authorized Individual) (Date) The person signing for the Business/Entity named on this application hereby affirms that she/he is authorized to act on behalf of such Business/Entity with regard to use of a Prepaid Account with the Department of State, agrees to the terms and conditions of having a Prepaid Account, and acknowledges that the Department of State is relying on her/his representations to that effect. PPAccntDebit Rev. 5/17/2010 American LegalNet, Inc. www.FormsWorkFlow.com