Credit Debit Card Authorization Form | Pdf Fpdf Doc Docx | Missouri

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Credit Debit Card Authorization Form | Pdf Fpdf Doc Docx | Missouri

Credit Debit Card Authorization Form

This is a Missouri form that can be used for Electronic Case Filing within Federal, District Court, Eastern District.

Alternate TextLast updated: 5/8/2006

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United States District Court Eastern Dis trict of Missouri 314-244-7900 CREDIT/DEBIT CARD AUTHORIZATION FORM I hereby authorize the U.S. District Court for the East ern District of Missouri to charge the card listed below for payment offees which are incurred by the authorized users. I certify that I am authorized to sign this form on behalf of my law firm or corporationand/or that I am the person authorized to use this card. I understa nd that this information will be securely maintained by the Court. Ialso understand that when an initiating petition requiring a fee is received through the electronic court filing system, the Court willautomatically charge the account number listed on the form. New Appl icant Renewal Applicant Cardholder Name as it appears on card: Billing Address City/State Card Num ber: Expiration Date: Signature of Card Holder: Date: Type: Mastercard Visa Discover American Express Other Additional names and signatures of individuals authorized to use account num ber listed above for payment of fees: Law Firm Name: (If sole practitioner, type in your name) Address: Immediate Contact Number: Alternate Contact Number: This form will remain in effect until the expiration date is met or specifically revoked in writing. It is the cardholders respons ibility tosubmit a new form and notify the court of: (1) any changes to the registered attorney or employee, (2) a new expiration date when acredit card has been renewed, or (3) a card has bee n revoked, canceled, or stolen. In the event the charge against the account is denied, you will be notified immediately to make payment in cash, money order or check. Any abuse of this privilege may res ult in your removal from the credit card program. Sub mit this form, with a ph otcop y o f the fron t and b ack of th e card to : Cashi er U.S. District Court - EDMO th 111 Sout h 10 Street, Rm 3.300 St. Louis, MO 63102 Note: Cas e related fees m us t have a credit card authorization form completed prior to the card being acce pted as payment.FOR COURT USE ONLY Re cd Entered Date Entered

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