The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, 17th Floor, Boston, Massachusetts 02108-1512 Domestic Profit Corp. Fax Filing Coversheet Please Print Neatly FAX INFORMATION Fax to: _________________________________________ Number of Pages (not including coversheet):_ ______________ 617-624-3891 Name of Entity being Filed:___________________________________________________________________________ Sender’s Name:___________________________________ Sender’s Telephone Number:____________________________ Senders Email address:_ ___________________________________________________________________________ E-check PAYMENT INFORMATION E-check Routing Number:__________________________ Check Account Number:_______________________________ CREDIT CARD PAYMENT INFORMATION Credit Card Type (please circle one): s r r TM Credit Card Number or Account Number:__________________________________ Security Indicator on VISA*:______ Name on Credit Card:_______________________________________________________________________________ Billing Address for Credit Card or E-Check Used Street:____________________________________________________________________________________________ City or Town:____________________________________ State:______________________Zip:_____________________ Telephone Number:_________________________________________________________________________________ Expiration Month:________________________________ Expiration Year:_ ____________________________________ *The Security Indicator is required for payment by Visa credit card. The security indicator is the non-embossed 3-digit number on the card signature panel found on the back of the card. In the signature panel, there is a large number (the account number) followed by a separate 3-digit number. You need the separate 3-digit number. There is an expedited service fee associated with fax filings. These fees cover the cost of the technical expertise necessary to provide the convenience of on-line and fax filing. You can obtain the expedited service fee associated with your filing by visiting our website at www.sec.state.ma.us/cor/corfees.htm and scrolling to the chart at the bottom of the page. American LegalNet, Inc. www.USCourtForms.com