NYS Department of State Uniform Commercial Code Division One Commerce Plaza, 99 Washington Avenue Albany, NY 12231-0001 www.dos.state.ny.us Credit Card Authorization MasterCard, Visa and American Express for payment of certain The Department of State’s Uniform Commercial Code Division accepts fees. To pay the fee for this transaction using a credit card, simply complete and sign this page and attach it to your document, if applicable. (Please note, omission of information may cause delay in the processing of your request.) PLEASE INDICATE TRANSACTION TYPE: ” ” UCC Filing ” UCC Search Deposit to Drawdown Account ACCOUNT # PLEASE INDICATE LEVEL OF SERVICE: (Please refer to fee schedule for specific filing and information request fees). Requests for expedited service must be received prior to 2:01 pm. ” ” Routine 24-Hour Expedite - Same Day $75 in addition to filing and/or search fees SUBMITTER’S INFORMATION: Entity Name: Service Companies Please Indicate Name & Number: Daytime telephone number: ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___ Total Amount Due: $ CARDHOLDER’S INFORMATION: ” Credit Card: Please print all information clearly, unclear or illegible information may result in rejection of your document(s). MasterCard ” ” Visa American Express Credit Card Number: Expiration Date: Month: Year: CARDHOLDER’S NAME (PRINT) CARDHOLDER’S BILLING ADDRESS AS LISTED WITH CREDIT CARD COMPANY CITY STATE ZIP CODE+4 Cardholder’s Signature Date FOR FILING OFFICE USE ONLY Authorization Number: Cash Number: Date: Transaction Number(s): DOS-0985 (4/09) American LegalNet, Inc. www.FormsWorkFlow.com