Certification Of Payment Of Processing Fee For The Form 33i - North Carolina Industrial Commission
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1I.C. No.
,
,
Employee, Plaintiff, v.
, Employer, and
, Carrier,
Defendants.
CERTIFICATION OF PAYMENT OF PROCESSING FEE FOR THE FORM 33I
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
by Check #
(person or entity sending payment)
to the North Carolina Industrial Commission as the processing fee for the Form 33I.
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 information of Certifier:
Telephone number of Certifier:
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