County Clerk Credit Card Payment Form
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1County Clerk Credit Card Payment Form
Date:
/
/
Name: ____________________________________________________
Business
: ___________________________________________
(optional)
Phone number: (____ ) _____- _________
Fax: (____) ______-_______
Email: ____________________________________________________
Authorized Signature: ________________________________________
This form authorizes the merchant (VitalChek) to charge my credit card, for services rendered by the County Clerk's office, plus a $2.50
service fee. A base percentage of 4% will be charged on credit transactions over $50.00. Please see our website for additional fees.
CLERK USE ONLY
Address to send document/s:
_______________________________________
:
TOTAL CHARGES
_______________________________________
$_____________
_______________________________________
***********************************************************************
* (Check which applies)
Master Card
Discover ____
American Express ____ Visa _____
*Name as it appears on Card: ____________________________________________
Credit Card Account Number:
_--___ ______
--
--
CVV# ___ ___ ___ (security code on back of card) *Exp. Date:
/
(MM/YY)
Billing Address: ______________________ City __________________ ZIP___________
**Note**
The ZI P Code
must
m atch the cardholder’s billing address; if not, the transaction w ill
be declined
.
*************************************************************************
Prices:
•
Birth Certificate: $23.00 each + credit card transaction fee
Death Certificate: $21.00 for first copy, $4.00 for each additional copy requested at same time +
•
credit card transaction fee
(application must be notarized)
•
Assumed Name/Abandonment of Assumed Name: $24.00
+ $0.50
per additional name + credit card transaction fee
•
Real Property Recording: $26.00 for first page + $4.00 Recording Page + $4.00 each additional
if applicable
page (
) + credit card transaction fee
Other fees may apply depending on document type. Please see our website for additional
o
fees.
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Parent category: Financial