NYS Department of State DIVISION OF CORPORATIONS One Commerce Plaza, 99 Washington Ave. Albany, NY 12231-0001 www.dos.state.ny.us Credit Card/Debit Card Authorization Attach this form to your document or written request. The Department of State’s Division of Corporations accepts MasterCard, Visa and American Express for payment of certain fees. The Name of Corporation or Other Business Entity To Which This Service Request Applies is: Check Box for Requested Service: Check Box for Requested Service: FILING OF DOCUMENTS AND CERTIFICATES *Optional Expedited Service for Additional Fee: CERTIFIED COPY Fill in Fee or Amount: $ (Consult appropriate fee schedule for filing fees) 24-Hour-$25 Same-Day-$75 2-Hour-$150 $ $ ($10 each) *Optional Expedited Service for Additional Fee: Same-Day-$75 $ 2-Hour-$150 $ PLAIN COPY ($5 each) *Optional Expedited Service for Additional Fee: CERTIFICATE UNDER SEAL 24-Hour-$25 Same-Day-$75 $ 2-Hour-$150 $ (Certificates of Good Standing, etc. $25 each) *Optional Expedited Service for Additional Fee: SERVICE OF PROCESS 24-Hour-$25 24-Hour-$25 Same-Day-$75 $ 2-Hour-$150 $ (Must be served in person at the above address) BIENNIAL / FIVE YEAR STATEMENT $ OTHER $ DEPOSIT TO DRAWDOWN $ Account Name: TOTAL (Total Amount Due): Account Number: $ *Same day expedited service requests must be received by 12 noon. 2 hour expedited service requests must be received by 2:30 p.m. Expedited service fees are non-refundable and will not be refunded if a filing is rejected. Credit/Debit Card Information: Credit/Debit Card Information: (Month and Year): (Print): (As listed with Credit Card or Debit Card Company) State: Cardholder’s Signature Zip Code+4: Date: If the name on the credit card or debit is in the name of a If the name on the credit card or debit cardcard is in the name of a corporation or other business entity, please the signer’s name: corporation or other business entity, please print print the signer’s name: DOS-1515-f-I (Rev. 02/10) American LegalNet, Inc. www.FormsWorkFlow.com