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Credit Card Authorization Form - Iowa
|Credit Card Authorization Form Form. This is a Iowa form and can be used in USDC Southern Federal .||
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United States District Court Southern District of Iowa Credit Card A uthorization FormINS TR UC TIO NS : Please type or print. Mail completed and signed form to:U.S. District Court, P. O. Box 9344, Des Moines, IA 50306-9344.Firm / Company: ______________________________________________Phone number: ___________________________Credit Card Type: VISA MasterCard Discover American ExpressCard Holder Name: ______________________________________________Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __Expiration Date: __ __ / __ __ (MM/YY)Credit Card Statement ______________________________________________Mailing Address: (Street address or P.O. Box)(Please be sure to list the address that the credit _______________________, __ __ Zip: __ __ __ __ __card company is sending (City, State & Zip)your statements to.) I acknowledge that the above information is accurate and that I am an authorized signerof the account. I hereby authorize the United States District Court for the SouthernDistrict of Iowa to charge the above credit card account court filing fees incurred by ourfirm or company. Date: __________________________________ Signature __________________________________ Print NameThis form, which will be kept on file in the Clerks Office, shall remain in effect until specificallyrevoked in writing. It is the responsibility of the attorney/firm named above to notify the ClerksOffice of the new expiration date when a credit card has been renewed, or if a card has beencanceled or revoked.