Application for Charge Account MICHAEL A. MAURO Secretary of State State of Iowa
The business entity named below hereby applies for the establishment of a charge
account.The applicant agrees to abide by the terms and conditions pertaining to
the use of this account as listed on the reverse of this application. The applicant
agrees to be responsible for all charges made to the account by the business
entity.
_____________________________________________________________
____________________________________________
Name of Business Entity Business Entity Tax ID # (REQUIRED)
________________________________________________________________________________________________________________
Mailing Address City State ZIP
__________________________________________________
__________________________________________________
Billing Contact Name E-mail Address (optional)
__________________________________________________
__________________________________________________
Telephone Number Fax Number
________________________________________________________________________________________________________________
Nature of Applicant's Business
Annual Account Fee is $25.00. In the first year of service, the fee is pro-rated as follows:
Application
for
Charge Account
MICHAEL A. MAURO
Secretary of State
State of Iowa
Authorization Signature:______________________________________ Title: _____________________ Date: ____________
Would you like a PIN number which is required for filing documents electronically?
*YES NO
*If YES, you will also need to complete an "ELECTRONIC SERVICES APPLICATION AND AGREEMENT"
FOR OFFICE USE ONLY:
Date:
Account #:
PIN:
Approved:
Payment of annual fee enclosed.
(Make check payable to SECRETARY OF STATE.)
Charge annual fee to my account.
Annual Account Fee is charged annually in July to cover fiscal year period July through June each year.
Review Terms and Conditions on Reverse Side
Service Begins
First Year Fee
Service Begins
First Year Fee
Service Begins
First Year Fee
July
$25.00
November
$16.50
March
$8.25
August
$22.25
December
$14.50
April
$6.25
September
$20.75
January
$12.50
May
$4.00
October
$18.75
February
$10.25
June
$2.00
SECRETARY OF STATE
Attn: Accounting
Lucas Building,1st Floor
Des Moines, IA 50319
Phone: (515) 281-5247
FAX: (515) 281-7142
Applicants for charge accounts with the Office of the Secretary of State shall be subject to the following
terms and conditions affecting their account:
1.
The Secretary of State may prescribe and furnish forms for the purpose of authorizing a charge to be
made upon an account. The Secretary of State may refuse to charge an account for service requested
without the appropriate form.
2.
Application for an account shall be made upon a form prescribed and furnished by the Secretary of State.
The account holder is subject to the terms and conditions contained in the application. The Secretary of
State reserves the right to adopt changes to the terms and conditions of the account. The Secretary of
State reserves the right to close a delinquent account.
3.
A valid federal tax identification number (EIN) is required of all applicants. Failure to provide a valid EIN is
a valid basis for the declination of a charge account. The EIN will be used to assist in the recovery of
delinquent accounts.
4.
Account holders will receive a monthly statement of account. The statement will include, for each
transaction, the date and amount of the transaction. A transaction may include more than one filing fee.
5.
Payment in full is due within 15 days of the date of statement of account. An account is considered
delinquent after the expiration of 30 days from the date of statement of account. Interest and finance
charges may be assessed on delinquent accounts in accordance with Iowa Code Chapter 535.
6.
An annual fee of $25.00 shall be paid by an account holder for the privilege of maintaining an account. In
the first year of service, this fee shall be pro-rated for the month in which the account is established (see
chart below). Annually in July, the annual account fee of $25.00 will automatically be billed to the account.
This fee shall cover a 12-month period beginning July 1 and ending June 30. The annual account fee shall
be used for the purpose of offsetting the expenses incurred by the Secretary of State in maintaining the account.
Application
for
Charge Account
Terms and Conditions
MICHAEL A. MAURO
Secretary of State
State of Iowa
Service Begins
First Year Fee
Service Begins
First Year Fee
Service Begins
First Year Fee
July
$25.00
November
$16.50
March
$8.25
August
$22.25
December
$14.50
April
$6.25
September
$20.75
January
$12.50
May
$4.00
October
$18.75
February
$10.25
June
$2.00
SECRETARY OF STATE
Attn: Accounting
Lucas Building,1st Floor
Des Moines, IA 50319
635_0091
rev 1/09
Phone: (515) 281-5247
FAX: (515) 281-7142
www.sos.state.ia.us