Free PDF - Minnesota

UNITED STATES DISTRICT COURT DISTRICT OF MINNESOTA REQUEST FOR CREDIT CARD PAYMENT
I hereby authorize the United States District Court for the District of Minnesota 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: Credit card Billing Address:
[Street, PO Box Other]

Date:

[City, State, Zipcode]

Contact Person Name:

Phone Number:

CARD INFORMATION
**ATTACH A PHOTOCOPY OF THE FRONT AND BACK OF THE CREDIT CARD TO THIS APPLICATION** ACCOUNT NUMBER: Mastercard Visa Discover EXPIRATION DATE: American Express Diners

Reason for Payment
SHORT CASE TITLE: (required)

Transaction (new case, appeal, copies, etc.)

Documents Sent
Enclosed In advance on Will be sent on by E-mail Mail Courier Enclosed In advance on Will be sent on by E-mail Mail Courier Enclosed In advance on Will be sent on by E-mail Mail Courier Enclosed In advance on Will be sent on by E-mail Mail Courier

Amount $ $ $ $ $

TOTAL CHARGES

Fax this form and photocopy of your credit card to one of the Clerk's Offices between the hours of 8am ­ 5pm CST:
Minneapolis (612) 664-5033 St. Paul (651) 848-1109 Duluth (218) 529-3505 Fergus Falls (218) 739-5325

NOTE: If you sent your complaint in paper, be sure to fax this form to the office that has your paper documents.