NYS Department of State Uniform Commercial Code Unit One Commerce Plaza, 99 Washington Avenue Albany, NY 12231-0001 www.dos.ny.gov Credit Card Authorization The Department of State's Uniform Commercial Code Unit accepts MasterCard, Visa and American Express for payment of certain 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. DEBTOR: Name: Contact Name: Daytime telephone number: ( Total Amount Due: $ ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___ 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 2:30 p.m. Routine 24-48 Hours Expedite - Same Day $75 in addition to filing and/or search fees. CARDHOLDER'S INFORMATION: Credit Card: Credit Card Number: Expiration Date: Month: MasterCard -- Please print all information clearly, unclear or illegible information may result in rejection of your document(s). Visa -- Year: American Express -- CARDHOLDER'S NAME (PRINT) CARDHOLDER'S BILLING ADDRESS AS LISTED WITH CREDIT CARD COMPANY CITY STATE ZIP CODE+4 Cardholder's Signature FOR FILING OFFICE USE ONLY Date Authorization Number: Cash Number: Date: Initials: Transaction Number(s): DOS-0985-f-l (02/12) American LegalNet, Inc. www.FormsWorkFlow.com