Last updated: 11/30/2016
Credit Card Payment Transmittal Form
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Description
Credit Card Payment Transmittal Form [All fields on form are required.] Order Information: [description of what payment is for e.g. name of filing this form is attached to] Name: [enter name exactly as it appears on credit card] Billing Address: [city] [state] [zip code] Telephone Number: Type of Card: Mastercard Card Number: Expiration [MM/YY]: Authorized Charge: All fields on the transmittal form are required. Your payment cannot be processed if all fields are not complete. Note: In accordance with the contract between the State of Idaho and our service provider Access Idaho, a $1 nonrefundable fee is added to each transaction. The Secretary of State's office does not keep any part of this fee. Privacy Notice: This form is used to process your credit card payment for a filing or service with the Idaho Secretary of State's office. Your credit card information is NOT retained in our office. The information you enter on this page is not sent or saved anywhere. The printed form that you send to us is shredded after your filing or service request is processed. Department direct fax numbers: Business Entities: 208 3342080 Elections: 208 3342282 Notaries & Trademarks: 208 3343400 UCC / Liens: Fiscal: All Other Departments: 208 3342847 208 3345224 208 3342282 / American LegalNet, Inc. www.FormsWorkFlow.com
