UNITED STATES DISTRICT COURT DISTRICT OF KANSAS
CREDIT CARD AUTHORIZATION FORM FOR CRIMINAL DEBT PAYMENT
I hereby authorize the United States District Court for the District of Kansas to charge the credit card listed below for criminal debt payments upon my request via telephone. Credit Cardholder Name: Address: Telephone Number: Driver's License Number: Signature: Fax Number: Driver's License State: Date:
Card Type (Visa, Mastercard, Discover, American Express, Diners Club) Card Number: Expiration Date: Security Code:________________ Mail the original of this form to: CLERK, UNITED STATES DISTRICT COURT FINANCIAL DEPARTMENT 500 STATE AVE., RM 259 KANSAS CITY, KS 66101
Note: A copy of the cardholder's driver's license or other identification along with a copy of both sides of the referenced credit card must be returned with this form. 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1) authorized users change; 2) a credit card has been renewed resulting in a new expiration date; and 3) a card has been revoked, canceled, or stolen.