Free Application One Time Credit Card Authorization - Louisiana


File Size: 12.0 kB
Pages: 1
Date: October 14, 2005
File Format: PDF
State: Louisiana
Category: Bankruptcy
Author: dweaver
Word Count: 117 Words, 1,701 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lawb.uscourts.gov/forms/One_Time_Auth_V27.pdf

Download Application One Time Credit Card Authorization ( 12.0 kB)


Preview Application One Time Credit Card Authorization
10/05

UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF LOUISIANA CREDIT/DEBIT CARD ONE-TIME AUTHORIZATION FORM
I hereby authorize the United States Bankruptcy Court for the Western District of Louisiana to charge the following bank card number for payment of filing fees and other court related expenses as designated on this form. Name as it appears on Card: Signature of Cardholder: Name of Law Firm/Business: Billing Address:
(Street, P.O.Box, Other)

______________________________________

Date: _______________________

(City, State, Zip Code)

Telephone Number:

Fax Number:

CARD INFORMATION
ACCOUNT NUMBER: EXPIRATION DATE:

9 American Express

9 Visa

9 Master Card

9 Discover

9 Diners Club

CHARGE INFORMATION:
CASE NUMBER ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

Please list the appropriate amounts for each applicable charge. FILING/SERVICE FEE AMOUNT $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________

DEBTOR NAME

_____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________

TOTAL CHARGES

$_____________