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Credit Card Collection Authorization Form - Kentucky
| Credit Card Collection Authorization Form Form. This is a Kentucky form and can be used in Western District Bankruptcy Court Federal . |
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U.S. Bankruptcy Court Credit Card Authorization Western District of Kentucky Form UNITED STATES BANKRUPTCY WESTERN DISTRICT OF KENTUCKY CREDIT CARD COLLECTION AUTHORIZATION FORM ____________________________________________________________________ (Name of Company/Firm) hereby authorizes the United States Bankruptcy Court for the Western District of Kentucky to charge the following bank card number(s) for payment for filing fees and other court related expenses. PLEASE PRINT: Type of Credit Card (VISA, Master Card, American Express, Discover or Diners Club): _________________________ Card Number: ____________________________________________________ Expiration Date: __________________ Billing Address: Street: ________________________________________________ City: ___________________ State: ____________ Zip Code: __________ Phone Number: ____________________ Fax Number: __________________ Contact Person (in the event that further information is required, e.g., verification of runner/couriers authority to charge fees to above account) ___________________ This form will be kept on file in the Clerks office, and shall remain in effect until specifically revoked in writing. It is the responsibility of the firm/company named herein to provide written notification to the Clerks office if a card has been canceled or revoked, and to file an updated Credit Card Collection Authorization Form when modification of any of the above information is necessary, including modification of the expiration date when a credit card is renewed. In the event the charge against this account is denied, you will be notified immediately to make payment in cash, money order or certified check. Any abuse of this privilege may result in your removal from the credit card program. Signature: ________________________________ Date: ______________ Typed Name: PLEASE RETURN COMPLETED FORM TO THE FINANCIAL DEPARTMENT, U.S. BANKRUPTCY COURT, 601 WEST BROADWAY, SUITE 450, LOUISVILLE, KY 40202-2264 <<<<<<<<<********>>>>>>>>>>>>> 2 This page was last edited on 09/10/2002 at 04:31 PM . Comments and Feedback
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