Free Microsoft Word - Document1 - Washington


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State: Washington
Category: Secretary of State
Author: smorris
Word Count: 235 Words, 1,802 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.secstate.wa.gov/_assets/corps/FaxPayment.pdf

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For use when paying fees by Credit/Debit Card Filing by fax is subject to an additional $20.00 expedited filing fee, per entity. Chapter 434-112080 WAC
Completed faxed requests are returned via standard mail, customer requests are not returned by fax

DATE:

CREDIT/DEBIT PAYMENT AUTHORIZATION
All submissions are subject to filing and legibility requirements pursuant to Chapter 434-112-040 (5) WAC & 434-112-045 WAC

TRACKING I.D. NUMBER:
(Only for previously submitted documentation)

NAME OF ENTITY:____________________________________________________________

UNIFIED BUSINESS IDENTIFIER NUMBER (UBI):_______________________________________________

TYPE OF SERVICE REQUESTED:

VISA, MASTERCARD, OR AMERICAN EXPRESS
CREDIT CARD NUMBER: CARDHOLDER NAME AND BILLING ADDRESS: Name: ________________________________ (As it appears on the credit/debit card) EXPIRATION DATE:

Address: _____________________________________________ (As it appears on the billing statement) City__________________________________ State ______ Zip Code _______ __ EXACT PAYMENT AMOUNT AUTHORIZED: $ X __________________________________________________________________________ Authorized Signature Printed Name Date Phone Number

Office of the Secretary of State, Division of Corporations and Charities

Fax (360) 664-8781 or Fax (360) 664-0055
All questions regarding fax filing should be directed to (360) 725-0377
This attachment may contain confidential and privileged information. If you are not the intended recipient, please destroy this document immediately, and notify the sender by phone or fax. Any dissemination or use of this information by a person other than the intended recipient is unauthorized. Payment Authorization Washington Secretary of State
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This Box For Office Use Only

Revised 02/09