Free Prepaid Account Application - Wyoming

Wyoming Secretary of State
State Capitol Building, Room 109 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.5343 Fax 307.777.5339 Email: [email protected]

For Office Use Only

A PAD is a Prepaid Account Deposit with the Secretary of State used for payment of transaction fees. A PAD does not accrue interest. A PAD is identified by its numerical code which will be provided upon PAD formation.

Application for Prepaid Account New PAD Name of Firm: Address: City/State/Zip Code: Contact Person: Contact Phone: Beginning Deposit Amount: $ Beginning Deposit Payment Method: Amending Existing PAD; Account #:

Monthly PAD statements and receipts evidencing payment deducted from a PAD will be sent to the contact person at the PAD address of record. Please notify the Secretary of State in writing (fax, email, or letter) if the PAD information changes. The following person(s) is/are authorized personnel to sign on behalf of the PAD Subscriber. By signing this document, the Subscriber authorizes the Secretary of State to establish a prepaid account which may be used by the Subscriber to pay for transactions with the Secretary of State's Office. If additional authorized persons are to be listed, please attach a separate page. The Subscriber shall be responsible for ensuring that appropriate funds are available within the account. The account may be suspended and/or terminated by either party upon written notification.

____________________________________ Original Signature of Authorized Person

___________________________ Date

____________________________________ Printed Name of Above Signer

____________________________________ Original Signature of Authorized Person

___________________________ Date

____________________________________ Printed Name of Above Signer