Certification Of Payment Of Processing Fee For Compromise Settlement Agreements

North Carolina Industrial Commission 1240 Mail Service Center Raleigh, North Carolina 27699-1240 I.C. No. , Employee, Plaintiff, v. , Employer, and, Carrier, Defendants. CERTIFICATION OF PAYMENT OF PROCESSING FEE FOR COMPROMISE SETTLEMENT AGREEMENT I hereby certify and attest that payment in the amount of $ has been sent by on (U.S. Mail or other method of delivery) (date) by (person or entity sending payment) by Check # as the processing fee for the Compromise Settlement to the North Carolina Industrial Commission. This the day of , . Signature of Certifier Print Name Title of Certifier: (attorney/adjuster/other) E-mail address of Certifier: Other address information of Certifier: Fax number of Certifier: Telephone number of Certifier: American LegalNet, Inc. www.FormsWorkFlow.com