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Credit Card Authorization Form - Iowa
| Credit Card Authorization Form Form. This is a Iowa form and can be used in Attorney USDC Northern Federal . |
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United States District Court Northern District of Iowa ***Credit Card Authorization Form for Payments Processed Over the Phone*** I hereby authorize the United States District Court for the Northern District of Iowa to charge the credit card listed below for payment upon my request via telephone. Credit Cardholder Name: __________________________________ Address:_______________________________________________ _____________________________________________________ Telephone #: ________________ Fax #: _______________ Driver's License #: _____________________ License State: _______ Signature: ___________________________ Date: ______________ ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Card Type: ________________ Card #: ____________________________________ Expiration Date: __________________ ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Mail the Original of this form to: United States District Court Attn: Finance 4200 C Street SW Cedar Rapids, IA 52404 A copy of the cardholder's driver's license or other identification along with a copy of both sides of the referenced credit card must be returned with this form. This form will be stored in the court's vault and will remain in effect until the cardholder specifically revokes it in writing. It is the responsibility of the cardholder named above to submit a new form and notify the court when: 1) the credit card has been renewed resulting is a new expiration date and 2) a card has been revoked, canceled or stolen. To charge a payment to your credit card, call our Cedar Rapids office @ 319.286.2300 or our Sioux City office @ 712.233.3840. (8:00 AM 4:30 PM Monday Friday) American LegalNet, Inc. www.FormsWorkFlow.com
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