Credit Card - One Time-Mail Authorization Form

THIS FORM MUST BE TYPED, FILLED OUT COMPLETELY WITH ORIGINAL SIGNATURE(s) AND SUBMITTED WITH THE PLEADING(S) AT THE TIME OF FILING. The signature field must be signed by the person whose signature appears on the back of the creditcard. A photocopy of both sides of the credit card MUST accompany this form. Photo identification will be requested from persons designated as authorized users. UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF NEW YORK CREDIT CARD - ONE TIME/MAIL AUTHORIZATION FORM Credit Cardholder Name: Card Type: MasterCard Visa Discover American Express DinersClub Account No.: AmEx ID#: Exp.Date: Billing Address: E-mail address: Phone #: I authorize the following person to use the above card for services as checked below: Name: Signature: Signature of CardHolder: Copy of credit card (both sides) attached CHARGE INFORMATION: Filing Fee (new case) Motion Fee Conversion Fee Search FeeCopies Certification Appeal Complaint File Retrieval from Archives Other Fees for the above pleadings will be charged in accordance with the current Bankruptcy Court Miscellaneous Fee Schedule. All original authorizations forms will be stored in a secure location in the Buffalo office.