United States Bankruptcy Court Southern District of Illinois 750 Missouri Avenue East St. Louis, Illinois 62234 (618) 482-9427 Fax (618) 482-9414 CREDIT CARD AUTHORIZATION FORM ONE TIME AUTHORIZATION To the Attention of: ____________________________________________________________Name of Debtor(s) : ____________________________ Case Number : ___________________I hereby authorize the United States Bankruptcy Court for the Southern District of Illinois to chargethe credit card noted below for payment of fees, costs and expenses which are listed below. I certifythat I am a person who is authorized to use this credit card. Name: _____________________________________ Address: _____________________________________________________________________ Signature: _____________________________________ Date: ________________________Daytime telephone number: _______________________ Zip Code:____________________Information about card: American Express No. _________________________ Expiration Date: __________ Diners Club No. _____________________________Expiration Date: __________ Discover No. ________________________________Expiration Date: __________ MasterCard No. ______________________________Expiration Date: __________ VISA No. __________________________________Expiration Date: __________Information about the charge: Please check the appropriate box and the amounts: Filing Fee(s) (for new or reopened cases)$___________ Motion Fee(s) $___________ Conversion Fee $___________ Search Fee $___________ Copies and certification $___________ Appeal Filing Fee(s) $___________ Archive File Retrieval $___________ Other: ____________________________$___________ Total Charge $___________ You must photocopy your credit card (both sides) and return a copy with this form.