Free l - Georgia

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF GEORGIA
CREDIT CARD AUTHORIZATION FORM
(Name of Company/Firm) hereby authorizes the United States District for the Middle District of Georgia 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:________________________ Fax Number:__________________________ Signature:______________________________________ Date:__________________________ Card Type (Visa, MasterCard, Discover, American Express, Diners Club)__________________ Card Number:_________________________________________________________________ Expiration Date:___________________________ INDIVIDUALS AUTHORIZED TO USE ABOVE CREDIT CARD ACCOUNT ____________________________________ ______________________________ ____________________________________ ______________________________ ____________________________________ ______________________________ Mail the original form to: CLERK, UNITED STATES DISTRICT COURT POST OFFICE BOX 128 MACON, GA 31202

This form will be stored in the court's vault for safekeeping purposes 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1) authorized users change; 2) a credit card has been renewed resulting in a new expiration date; and 3) a card has been revoked, canceled or stolen.