American LegalNet, Inc. www.FormsWorkFlow.com Secretary of the State 30 Trinity Street Mailing Address: P.O. Box 150470 Hartford, CT 06115-0470 Refund Claim for Overpaid Fees Refunds will not be processed unless they comply with Connecticut General Statues sec. 3-99a(c), which states in part that the amount must be in excess of $5.00 and not have accrued for more than one year in order to be refunded. Additionally, a copy of the front and back of the negotiated check, cash receipt or credit card receipt will be required in order to process a refund claim along with any supporting documentation such as a rejection letter or notice of money on account. The following information is required to accurately process a refund: I am the only person or entity having a valid claim to the monies being held on account at the office of the Secretary of the State. I request the check be made payable as follows: (Mailing address, include your reference # if desired) Work order # Customer ID # Processing # Refund Amount $ The forgoing is made under the penalties of false statement Print Name: Title: Signature: Date: Below is for Official Use by The Office of The Secretary of The State of Connecticut Amount Orig. Dep. # Deposit Date Approved By List# SOS-REF-08 Rev. 1/7/11 American LegalNet, Inc. www.FormsWorkFlow.com