"Prepaid Account Debit Form" - Colorado

Prepaid Account Debit Form is a legal document that was released by the Colorado Secretary of State - a government authority operating within Colorado.

Form Details:

  • Released on May 17, 2010;
  • The latest edition currently provided by the Colorado Secretary of State;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Secretary of State.

ADVERTISEMENT
ADVERTISEMENT

Download "Prepaid Account Debit Form" - Colorado

232 times
Rate (4.4 / 5) 16 votes
Deliver to: Colorado Secretary of State
1700 Broadway, Suite 200
Denver, CO 80290
(303) 894-2200
ABOVE SPACE FOR OFFICE USE ONLY
Prepaid Account Debit Form
The Prepaid Account Holder identified below instructs the Colorado Secretary of State to debit their Prepaid Account as stated below
in the amount indicated for payment of the fee(s).
Prepaid Account Number
The total amount to be debited is $
(Optional) Expedited Service
Mark the box if Expedited Service is available and requested for this transaction. An additional service
fee will apply. Fees can be found on the online Fee Schedule at www.sos.state.co.us.
Describe transaction:
(example: "file Statement of Foreign Entity Authority for ABC Corp")
The Account Holder’s name and address are
Business/Entity Name
Business/Entity Address
(Number and Street Name)
(City)
(State)
(ZIP/Postal Code)
(Province and Country, if applicable)
Authorized Individual
(Name)
(Title)
(Telephone Number, with Area Code)
(Fax Number, with Area Code)
(E-mail address)
(Optional) The Account holder's Job Number for this transaction is
(A Job Number may consist of twelve characters, alpha and/or numeric. It will appear next to this transaction on the monthly
statement issued for this Prepaid Account.)
(Optional) Account Holder's additional information pertaining to this transaction
(This information is for the use of the Account Holder only. It will not appear on the monthly statement issued for this Prepaid Account.)
(Signature of Authorized Individual)
(Date)
The person signing for the Business/Entity named on this application hereby affirms that she/he is authorized to act on
behalf of such Business/Entity with regard to use of a Prepaid Account with the Department of State, agrees to the terms and
conditions of having a Prepaid Account, and acknowledges that the Department of State is relying on her/his representations
to that effect.
Rev. 5/17/2010
PPAccntDebit
Deliver to: Colorado Secretary of State
1700 Broadway, Suite 200
Denver, CO 80290
(303) 894-2200
ABOVE SPACE FOR OFFICE USE ONLY
Prepaid Account Debit Form
The Prepaid Account Holder identified below instructs the Colorado Secretary of State to debit their Prepaid Account as stated below
in the amount indicated for payment of the fee(s).
Prepaid Account Number
The total amount to be debited is $
(Optional) Expedited Service
Mark the box if Expedited Service is available and requested for this transaction. An additional service
fee will apply. Fees can be found on the online Fee Schedule at www.sos.state.co.us.
Describe transaction:
(example: "file Statement of Foreign Entity Authority for ABC Corp")
The Account Holder’s name and address are
Business/Entity Name
Business/Entity Address
(Number and Street Name)
(City)
(State)
(ZIP/Postal Code)
(Province and Country, if applicable)
Authorized Individual
(Name)
(Title)
(Telephone Number, with Area Code)
(Fax Number, with Area Code)
(E-mail address)
(Optional) The Account holder's Job Number for this transaction is
(A Job Number may consist of twelve characters, alpha and/or numeric. It will appear next to this transaction on the monthly
statement issued for this Prepaid Account.)
(Optional) Account Holder's additional information pertaining to this transaction
(This information is for the use of the Account Holder only. It will not appear on the monthly statement issued for this Prepaid Account.)
(Signature of Authorized Individual)
(Date)
The person signing for the Business/Entity named on this application hereby affirms that she/he is authorized to act on
behalf of such Business/Entity with regard to use of a Prepaid Account with the Department of State, agrees to the terms and
conditions of having a Prepaid Account, and acknowledges that the Department of State is relying on her/his representations
to that effect.
Rev. 5/17/2010
PPAccntDebit