Certification Of Payment Of Processing Fee For Form 24 Application
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Certification Of Payment Of Processing Fee For Form 24 Application Form. This is a North Carolina form and can be use in Workers Comp.
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Tags: Certification Of Payment Of Processing Fee For Form 24 Application, North Carolina Workers Comp,
I.C. No.__________, _________________, Employee, Plaintiff, v.
__________________________, Employer, and _________________, Carrier, Defendants.
CERTIFICATION OF PAYMENT OF PROCESSING FEE
FOR FORM 24 APPLICATION
I hereby certify and attest that payment in the amount of $______________________________
has been sent by _________________________________ on __________________________
(U.S. Mail or other method of delivery)
(date)
by _______________________________________________ by Check # _________________
(person or entity sending payment)
as the processing fee for the Form 24 Application to the North Carolina Industrial Commission.
This the ____________ day of _____________, __________.
______________________________________________________________________________
Signature of Certifier
______________________________________________________________________________
Print Name
Title of Certifier: _______________________________________________________________
(attorney/adjuster/other)
E-Mail address of Certifier: ______________________________________________________
Other address information of Certifier: ______________________________________________
Fax information of Certifier: ______________________________________________________
Telephone number of Certifier: ____________________________________________________
*This certification is required for Form 24 Applications that are sent by e-mail submission.
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