Free Credit Card Authorization - Kansas

UNITED STATES DISTRICT COURT DISTRICT OF KANSAS
CREDIT CARD AUTHORIZATION FORM

(Name of Company/Firm) hereby authorizes the United States District Court for the District of Kansas to charge the credit card listed below for payment of filing fees and other court related expenses incurred by the individuals listed below. I certify that I am authorized to sign the form on behalf of my firm. Credit Cardholder Name: Address: Telephone Number: Signature: Fax Number: Date:

Card Type (Visa, Mastercard, Discover, American Express, Diners Club) Card Number: Expiration Date: Security Code:________________ INDIVIDUALS AUTHORIZED TO USE ABOVE CREDIT CARD ACCOUNT

Mail the original of this form to:

CLERK, UNITED STATES DISTRICT COURT FINANCIAL DEPARTMENT 500 STATE AVE., ROOM 259 KANSAS CITY, KS 66101

This form will be stored in the court's vault and will remain in effect until the cardholder specifically revokes it in writing. It is the responsibility of the cardholder and/or firm named above to submit a new form and notify the court when 1) authorized users change; 2) a credit card has been renewed resulting in a new expiration date; and 3) a card has been revoked, canceled, or stolen.