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Credit Or Debit One Time Authorization Form - Louisiana
| Credit Or Debit One Time Authorization Form Form. This is a Louisiana form and can be used in Western District Bankruptcy Court Federal . |
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CCAF 06/10 UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF LOUISIANA CREDIT/DEBIT CARD ONE-TIME AUTHORIZATION FORM I hereby authorize the United States Bankruptcy Court for the Western District of Louisiana to charge the following bank card number for payment of filing fees and other court related expenses as designated on this form. Name as it appears on Card: Signature of Cardholder: Name of Law Firm/Business: Billing Address: (Street, P.O.Box, Other) ______________________________________ Date: _______________________ (City, State, Zip Code) Telephone Number: Fax Number: CARD INFORMATION ACCOUNT NUMBER: EXPIRATION DATE: American Express Visa Master Card Discover Diners Club CHARGE INFORMATION: CASE NUMBER Please list the appropriate amounts for each applicable charge. FILING/SERVICE FEE AMOUNT DEBTOR NAME ______________ ______________ ______________ ______________ ______________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______________________ ______________________ ______________________ ______________________ ______________________ $______________ $______________ $______________ $______________ $______________ TOTAL CHARGES $______________ 0.00 Court Use Only: American LegalNet, Inc. www.FormsWorkFlow.com
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