Credit Card Blanket Authorization Form

UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF NEW YORK CREDIT CARD BLANKET AUTHORIZATION FORM I hereby authorize the U.S. Bankruptcy Court for the Western District of New York to charge the bank card listed below for payment of fees, costs and expenses which are incurred by the authorized users listed below. I understand if a document requiring a fee is received without the fee, the court will automatically charge the account number listed on this form. A copy of both sides of the credit card must accompany this form. I certify that I am authorized to sign this form on behalf of my law firm. THIS FORM MUST BE TYPED, FILLED OUT COMPLETELY WITH ORIGINAL SIGNATURES, AND DELIVERED TO THE U.S. BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF NEW YORK. A new original form must be submitted to the Court upon any change of any of the information below. It is the responsibility of the cardholder to notify the Court if a card has been stolen or cancelled. If the information on the form is not current, the transaction will not be processed. This form will remain in effect until the expiration date of the credit card or the form is specifically revoked in writing. Photo identification will be requested from the authorized users listed on this form when appearing personally at the Court. Name as it appears on card Card Type: " MasterCard " Visa " Discover " American Express " Diners Club Account Number: Security Code: Signature: AmEx ID#: Expiration Date: Date: Names and signatures of individuals authorized to use account number listed above for payment of fees, costs, or expenses: Name Signature Name Signature Name Name of Firm: Signature (Sole practitioner, type or print your name) Billing Address: Contact Person: e-mail address: Please send your form to: U.S. Bankruptcy Court, WDNY 300 Pearl St., Suite 250 ATTN: Admin. Manager Buffalo, NY 14202 Phone No: Court Use Only: Date Received: CC copy attached: Y N Info verified: Y N By: Rev. 10/15/10 American LegalNet, Inc. www.FormsWorkFlow.com