Free Authorization.PDF - Virginia

INSTRUCTIONS FOR COMPLETING FORM: This form must be typed. The signature field must be signed by the person whose signature appears on the back of the credit card. You must photocopy your credit card (BOTH SIDES) and attach the copy to this form.

United States Bankruptcy Court ­ Eastern District of Virginia CREDIT CARD ONE TIME AUTHORIZATION FORM
I hereby authorize the U. S. Bankruptcy Court for the Eastern District of Virginia to charge the credit card listed below for payment of fees, costs, and expenses which are listed below. I certify that I am authorized to use this credit card.

Credit Cardholder Name: _____________________________________________________ Signature: ______________________________________ Date: ________________

Company/Firm Name: ________________________________________________________ Address: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Telephone Number: ________________________________ CARD TYPE: (Check card type below) MasterCard
account number.)

VISA

Discover

American Express **

Diners Club

** American Express ID Number:______ (This four digit number is printed on your card above the embossed Account Number:___________________________________ Exp. Date: ____________

CHARGE INFORMATION: Please list the appropriate amounts for each applicable charge. Filing Fee (for new cases) Motion Fee Conversion Fee Search Fee Copies made by court - number of copies: Certification Fee Appeal Fee File Retrieval from Archives Complaint Fee Other:_______________________________________ TOTAL CHARGES Court use only: Receipt # _________________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ [Revised 12/04/03]

Date ____________________