Credit Card Payment Transmittal Form [all fields on form are required] Order Information: [description of what payment is for - for example: name of filing this form is attached to] Name: [enter name exactly as it appears on credit card] Billing Address: [city] [state] [zip code] Telephone Number: Type of Card: Mastercard Visa American Express Discover Card Number: Expiration [mm/yy] Authorized Charge: All fields on the transmittal form are required. Your payment cannot be processed if all fields are not complete. Note: In accordance with the contract between the State of Idaho and our service provider Access Idaho, a $1 non-refundable fee is added to each transaction. The Secretary of State's office does not keep any part of this fee. Privacy Notice: This form is used to process your credit card payment for a filing or service with the Idaho Secretary of State's office. Your credit card information is NOT retained in our office. The transmittal form is shredded after your filing or service request is processed. Business Entities: UCC / Liens: Elections: Notaries & Trademarks: (208) 334-2080 Fiscal: All Other Departments: (208) 334-2282 Department Direct Fax Numbers: (208) 334-2080 (208) 334-2847 (208) 334-2282 (208) 334-5224 American LegalNet, Inc. www.FormsWorkflow.com