Free 635_0091.p65 - Iowa


File Size: 57.2 kB
Pages: 2
Date: January 13, 2009
File Format: PDF
State: Iowa
Category: Secretary of State
Author: mstadlman
Word Count: 699 Words, 4,829 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.sos.state.ia.us/pdfs/AcctDownload/charge_app.PDF

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MICHAEL A. MAURO Secretary of State State of Iowa

Application for Charge Account
FOR OFFICE USE ONLY:
Date: Account #: PIN: Approved:

The business entity named below hereby applies for the establishment of a charge account.The applicant agrees to abide by the terms and conditions pertaining to the use of this account as listed on the reverse of this application. The applicant agrees to be responsible for all charges made to the account by the business entity.

_____________________________________________________________
Name of Business Entity

____________________________________________
Business Entity Tax ID # (REQUIRED)

________________________________________________________________________________________________________________
Mailing Address City State ZIP

__________________________________________________
Billing Contact Name

__________________________________________________
E-mail Address (optional)

__________________________________________________
Telephone Number

__________________________________________________
Fax Number

________________________________________________________________________________________________________________
Nature of Applicant's Business

Authorization Signature:______________________________________ Title: _____________________ Date: ____________

Annual Account Fee is $25.00. In the first year of service, the fee is pro-rated as follows:
Service Begins
July August September October

First Year Fee
$25.00 $22.25 $20.75 $18.75

Service Begins
November December January February

First Year Fee
$16.50 $14.50 $12.50 $10.25

Service Begins
March April May June

First Year Fee
$8.25 $6.25 $4.00 $2.00

Annual Account Fee is charged annually in July to cover fiscal year period July through June each year.

Payment of annual fee enclosed. (Make check payable to SECRETARY OF STATE.) Charge annual fee to my account. Would you like a PIN number which is required for filing documents electronically?

*YES

NO

*If YES, you will also need to complete an "ELECTRONIC SERVICES APPLICATION AND AGREEMENT"
SECRETARY OF STATE Attn: Accounting Lucas Building,1st Floor Des Moines, IA 50319 Phone: (515) 281-5247 FAX: (515) 281-7142

Review Terms and Conditions on Reverse Side

MICHAEL A. MAURO Secretary of State State of Iowa

Application for Charge Account

Terms and Conditions

Applicants for charge accounts with the Office of the Secretary of State shall be subject to the following terms and conditions affecting their account:

1.

The Secretary of State may prescribe and furnish forms for the purpose of authorizing a charge to be made upon an account. The Secretary of State may refuse to charge an account for service requested without the appropriate form. Application for an account shall be made upon a form prescribed and furnished by the Secretary of State. The account holder is subject to the terms and conditions contained in the application. The Secretary of State reserves the right to adopt changes to the terms and conditions of the account. The Secretary of State reserves the right to close a delinquent account. A valid federal tax identification number (EIN) is required of all applicants. Failure to provide a valid EIN is a valid basis for the declination of a charge account. The EIN will be used to assist in the recovery of delinquent accounts. Account holders will receive a monthly statement of account. The statement will include, for each transaction, the date and amount of the transaction. A transaction may include more than one filing fee. Payment in full is due within 15 days of the date of statement of account. An account is considered delinquent after the expiration of 30 days from the date of statement of account. Interest and finance charges may be assessed on delinquent accounts in accordance with Iowa Code Chapter 535. An annual fee of $25.00 shall be paid by an account holder for the privilege of maintaining an account. In the first year of service, this fee shall be pro-rated for the month in which the account is established (see chart below). Annually in July, the annual account fee of $25.00 will automatically be billed to the account. This fee shall cover a 12-month period beginning July 1 and ending June 30. The annual account fee shall be used for the purpose of offsetting the expenses incurred by the Secretary of State in maintaining the account.
Service Begins July August September October First Year Fee $25.00 $22.25 $20.75 $18.75 Service Begins November December January February First Year Fee $16.50 $14.50 $12.50 $10.25 Service Begins March April May June First Year Fee $8.25 $6.25 $4.00 $2.00

2.

3.

4. 5.

6.

SECRETARY OF STATE Attn: Accounting Lucas Building,1st Floor Des Moines, IA 50319

Phone: (515) 281-5247 FAX: (515) 281-7142

635_0091 rev 1/09

www.sos.state.ia.us