The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, 17th Floor, Boston, Massachusetts 02108-1512 UCC Fax Filing Coversheet Please Print neatly FAX INFORMATION 617-624-3891 Fax to: ________________________________________ Number of Pages (not including coversheet): ______________ 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.FormsWorkflow.com