Free Credit Card Authorization Form- (For Criminal Debt Payments Only) - Georgia

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF GEORGIA

CREDIT CARD AUTHORIZATION FORM FOR CRIMINAL DEBT PAYMENT

I hereby authorize the United States District for the Middle District of Georgia to charge the credit card listed below for criminal debt payments upon my request via telephone. Credit Cardholder Name:_________________________________________________________ Address:______________________________________________________________________ Telephone Number:________________________ Fax Number:__________________________ Driver's License Number____________________Driver's License State___________________ Signature:______________________________________ Date:__________________________ Card Type (Visa, MasterCard, Discover, American Express, Diners Club)__________________ Card Number:_________________________________________________________________ Expiration Date:___________________________

Mail the original form to:

CLERK, UNITED STATES DISTRICT COURT POST OFFICE BOX 128 MACON, GA 31202

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 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1) authorized users change; 2) a credit card has been renewed resulting in a new expiration date; and 3) a card has been revoked, canceled or stolen.