Paul D. Pate                                        Notice To:  
     
                                                                    Charge Account Customers 
                     Secretary of State 
                                                                    Regarding Filing Procedures 
                             State of Iowa 
                                                       
   To Customers with Charge Accounts: 
     
   1.  Decide if you are charging the fee to your account.  
     
       The Charge Transaction Form below must be filed with all filings for which you are charging the filing fee to 
       the charge account.  (When filing multiple filings simultaneously, one Charge Transaction Form is sufficient)  
     
   2.  Supply the invoice reference information on the form in the space provided.  
       This detail will appear on your billing to remind you of the subject of the particular filing. 
    
   3.  Ensure you are ready to send your filing and the             Charge Transaction Form together.  
        
       Documents not accompanied by the Charge Transaction Form will be returned but will not be filed. 
        
   4.  Mail or fax your filings to:                  Iowa Secretary of State’s Office 
                                                     First Floor, Lucas Building 
                                                     321 E. 12th St 
                                                     Des Moines, IA 50319 
                                                     Fax:  515-242-5953  
                                                     
                             Paul D. Pate 
                     Secretary of State                             Charge Transaction Form 

                             State of Iowa 
  
Instructions: Please type or print clearly. After completing this form, sign and date it.  Return this form with the filing 
to the secretary of state’s office for processing.    
 
1. Customer Account Number: ____________________________________________________ 
 
2. Customer Name: ______________________________________________________________ 
 
3. Invoice Reference: ____________________________________________________________ 
                                                     (This description will appear on your monthly statement. Maximum 30 characters.) 
 
4. Authorized Signature: _______________________________________ Date:_______________________ 
 
                                                    SHADED AREA - FOR OFFICE USE ONLY 
   
  Transaction Date: ____________________  ITEM CODE: ____________                          Amount: $ ______________