Credit Card Payment Authorization Form - Iowa Secretary Of State printable pdf download

Credit Card Payment Authorization Form - Iowa Secretary Of State

PAUL D. PATE

CREDIT CARD PAYMENT

Secretary of State

AUTHORIZATION FORM

State of Iowa

This authorization form must be completed and accompany your document or request if you are requesting

to pay the fee(s) by credit card. Complete the entire form. All information is required.

Indicate the type of document or request you are submitting:

Corporate Document(s):

Below, state the type of document and the legal title stated on the document.

Other Request(s):

Below, state the type of request and the name of the requesting party.

Provide all of the following information and authorization for the payment below:

Visa

MasterCard

Discover

___________ ____________ ___________ ___________

Credit Card Number

Expiration Date: ________/________ (MM/YY)

Cardholder’s name (as it appears on the card):

Cardholder’s Address:

(House Number)

(Street Name)

(Apt., STE., Lot) (City)

(State)

(Zip)

Cardholder’s daytime telephone number: (

)

Payment Authorization: I authorize the Office of the Iowa Secretary of State

to charge my credit/debit card the amount of fees due.

Cardholder’s Signature:

Secretary of State

Business Services Division

Lucas Building, 1st Floor

Des Moines, Iowa 50319

Phone: (515) 281- 5204

Fax:(515) 242-5953

Website:sos.iowa.gov

Credit Card Payment Authorization Form - Iowa Secretary Of State