Mississippi > Federal > Bankruptcy Court > Northern District
Credit Card Blanket Authorization - Mississippi
| Credit Card Blanket Authorization Form. This is a Mississippi form and can be used in Northern District Bankruptcy Court Federal . |
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(revised 1/27/2011) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF MISSISSIPPI CREDIT CARD BLANKET AUTHORIZATION (ATTACH A COPY OF THE FRONT AND BACK OF YOUR CREDIT CARD) PLEASE TYPE: Name of Firm:_________________________________________________________________ (If sole practitioner, type your name) Address:______________________________________________________________________ City:______________________________ State:_________________ Zip code:_____________ Telephone Number:_____________________ Contact Person:___________________________ hereby authorizes the United States Bankruptcy Court for the Northern District of Mississippi to charge the following credit card for payment of filing fees (and other fees approved for credit card use in the future) incurred by the authorized users listed below: CHECK ONE (Each Card Requires a Separate Authorization) Visa________ MasterCard_______ American Express________ Discover______ Diners______ CREDIT CARDHOLDER'S NAME:__________________________________________ STATEMENT MAILING ADDRESS: (required) Street or P.O. Box Number: _________________________________________ City:_________________________, State:____________________, Zip Code:_____________ CREDIT CARD # _______________________________ EXPIRATION DATE:___________ AUTHORIZED SIGNATURE:____________________________ DATE:________________ NAME OF INDIVIDUALS AUTHORIZED TO CHARGE TO THIS ACCOUNT: _______________________________ _____________________________ _______________________________ _____________________________ _______________________________ _____________________________ _______________________________ _____________________________ This form will be securely maintained on file in the Clerk's Office and shall remain in effect until specifically revoked in writing. It is the responsibility of the law firm/attorney named herein to notify the Clerk's Office when the information on this form has expired or changed, or if the card has been canceled or revoked. ________________________________________________________________________ FOR COURT USE ONLY: Date Received:__________________________ By:____________________________________ ______________________________________________________________________________ In the event a charge against this account is denied, you will be notified immediately to make payment in cash, money order or check. Any abuse of this privilege may result in your removal from the credit card program. Return Completed Form to: Edna T. Garth, Financial Administrator U.S. Bankruptcy Court, NDMS 703 Hwy 145 N Aberdeen, MS 39730 American LegalNet, Inc. www.FormsWorkFlow.com
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