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Credit Card Authorization Form For Criminal Debt Payment - Kansas
| Credit Card Authorization Form For Criminal Debt Payment Form. This is a Kansas form and can be used in District Court Federal . |
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UNITED STATES DISTRICT COURT DISTRICT OF KANSAS CREDI T CARD A UTHORI ZAT ION FORM FOR CRIMI NAL DEBT P AYMENTI hereby authorize the United States District Court for the District of Kansas to charge the creditcard listed below for criminal debt payments upon my request via telephone. Credit Cardholder Name: Address: Telephone Number: Fax Number: Drivers License Number: Drivers License State: Signature: Date: Card Type (Visa, Mastercard, Discover, American Express, Diners Club) Card Number: Expiration Date: Mail the original of this form to:CLERK, UNITED STATES DISTRICT COURT FINANCIAL DEPARTMENT 500 STATE AVE., RM 259 KANSAS CITY, KS 66101Note: A copy of the cardholders drivers license or other identification along with a copy ofboth sides of the referenced credit card must be returned with this form.This form will be stored in the courts vault and will remain in effect until the cardholderspecifically revokes it in writing. It is the responsibility of the cardholder and/or firm named above to submit a new formand notify the court when 1) authorized users change; 2) a credit card has been renewedresulting in a new expiration date; and 3) a card has been revoked, canceled, or stolen.
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