Free Credit Card Authorization Form - Arkansas


File Size: 468.8 kB
Pages: 1
File Format: PDF
State: Arkansas
Category: Bankruptcy
Author: tammy
Word Count: 206 Words, 1,309 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.arb.uscourts.gov/forms/ccauthfillable.pdf

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INSTRUCTIONS FOR COMPLETING FORM: This form must be typed and can be completed electronically on our website, www.arb.uscourts.gov/forms/ccauthfillable.pdf . Press the tab key to advance to each field. A handwritten signature is required. This form must be faxed to 501-918-5520.

United States Bankruptcy Court - Eastern & Western Districts of Arkansas ONE TIME CREDIT CARD AUTHORIZATION FORM
I hereby authorize the U.S. Bankruptcy Court to charge the credit card listed below for payment of fees, costs, and expenses which are listed below. I certify that I am a person who is authorized to use this credit card.
Credit Cardholder Name: Address:

Signature: Daytime Telephone Number:

Date: Fax Number:

CARD INFORMATION Account Number: CARD TYPE: **American Express ID Number: account number.) (This four digit # is printed on your card above the embossed Expiration Date:

CHARGE INFORMATION: Please check the appropriate box and insert the amount to be charged.

Filing fees Installment Fees Motion Fees Conversion Fee Search Fee Copies Certifications Appeal Fee Archived File Retrieval Adversary Fees Other:
TOTAL TO BE CHARGED

$0.00

Please list all debtors and case numbers:

What is the reason you are not filing electronically?
(Version 8/1/03)

Installment

Other (give reason below)

Clear Fees