Free 635_0092.p65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa

Electronic Services Application and Agreement
FOR OFFICE USE ONLY:
Date: Account #:

The below named applicant does hereby agree to the terms and conditions on the reverse side of this application regarding the electronic services of documents with the Iowa Secretary of State's Office.

Provide all of the following information:
This electronic services agreement is associated with the following account:

PIN: Approved:

Account Name: _______________________________________________________________________________________
(Applicant) List the account name exactly as request on the Charge Account Application Form

If this is a pre-existing account, list the account number for the above account: (if known) Account Number: _______________________________

List the name, address, phone number and e-mail address of the individual who will act as the E-services coordinator for the applicant.
________________________________________________________________________________________________________________
Name of E-service Coordinator

________________________________________________________________________________________________________________
Mailing Address City State ZIP

__________________________________________________
Telephone Number

__________________________________________________
E-mail Address

List a code word which should be known only to the E-services coordinator and our office. This code word is confidential and used for identifying the coordinator when he or she calls for assistance with PIN number. Code Word: ________________________________________________________

If this account is to be used for filing UCC documents, list the name and address as you would like it to appear on the UCC documents as the secured or authorizing party. Note: This will enable you (at your discretion) to fill out relevant portions of the UCC form without having to type it out each time you submit a filing.
________________________________________________________________________________________________________________
Name

________________________________________________________________________________________________________________
Mailing Address City State ZIP

________________________________________ ________________________________
Signature of Individual Authorizing This Agreement on Behalf of Applicant Title

________________
Date Signed

________________________________________
Print Name of Authorizing Individual

Fax to: (515) 281-7142

Review Terms and Conditions on Reverse Side

MICHAEL A. MAURO Secretary of State State of Iowa

Terms and Conditions of PIN Issuance for E-Services

Terms and Conditions
Applicant agrees to the following terms and conditions relating to electronic services with the Iowa Secretary of State's Office:

1. Applicant shall maintain a current account with the Secretary of State's Office and shall abide by all
terms and conditions of said account.

2. The account number and personal identification number (PIN) shall be used by the Iowa Secretary of
State's Office as authorization by the applicant to file documents with this office.

3. It shall be the responsibility of the E-services coordinator to maintain the security and integrity of the
account and PIN number issued.

4. Filings made pursuant to the account and PIN number are presumed to be valid filings by the applicant
and applicant agrees to be responsible for all charges related to said filings.

5. E-services coordinator agrees to contact the Iowa Secretary of State's Office in writing concerning any
security and integrity issues related to the use the account and PIN number

6. E-services coordinator may terminate an existing PIN number on behalf of the applicant or request a
change of PIN number by contacting the Iowa Secretary of State's Office. The Secretary of State shall notify the E-services coordinator in writing or by e-mail when such number has been changed or terminated and maintain a record of the transaction.

7. Third-party filers (such as law firms, etc.) are responsible for obtaining authorization to file on behalf of
each secured party for whom they undertake to file.

8. UCC electronic filings completed pursuant to this agreement are made pursuant to the requirements of
Iowa Code chapter 554 and 721 IAC 30.

9. This electronic services agreement is associated only with the account listed on this application. 10. The individual listed as the E-services coordinator in this form shall be the official contact for E-services
matters related to the applicant account as specified herein. This individual will have the ability to terminate or reissue the PIN number associated with the account number listed on this application.

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

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

635_0092 01/09

www.sos.state.ia.us