Last updated: 2/11/2011
Credit Card Payment Authorization Form
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Description
| Credit Card Payment Authorization Form If you wish to pay by MasterCard, Visa or Discover, complete the information below, detach and return to the Court with your Citation. You can not make a credit card payment over the Internet to 63rd District Court at this time. You must print this form and return it by mail, in person, or by fax at (616) 363-6211. I would like to charge my 63rd District Court payment to my MasterCard/Visa account. Amount of Payment $__________ NAME OF CARD HOLDER (EXACTLY AS IT APPEARS ON CARD) _________________________________________________________ MasterCard Account Number Visa Discover Expiration Date: __________ Cardholder Signature: __________________________________________ Today's Date: _________________ ** If you are submitting this payment for someone other than yourself, please indicate below the name of the person and/or case number for payment. NAME ____________________________ CASE # ___________________________ American LegalNet, Inc. www.FormsWorkFlow.com
