Free Credit Card Payment Information Form - New Hampshire

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE CREDIT CARD PAYMENT INFORMATION (MUST BE SUBMITTED WITH EACH PAYMENT OBLIGATION) YOUR OBLIGATION TO THE UNITED STATES DISTRICT COURT MAY BE SETTLED WITH YOUR VISA, MASTERCARD, DISCOVER,OR AMERICAN EXPRESS
INSTRUCTIONS: 1. Completely fill out all blanks to ensure proper processing of this credit card form. 2. Mail completed form to: Clerk, US District Court 55 Pleasant Street, Room 110 Concord, NH 03301-3941 Authorization number Authorization date Reference number

Accounting Use Only

Q Visa

Q MasterCard

Q Discover

Q American Express
Good thru:

My Bank Card Number is:

CVC2 Number: (This is the 3 or 4 digit code on the back of the credit card.)

Payment Amount: $ State reason for payment:

Case Number:

(Print)

Name _________________________________________________________________________________________ Address _______________________________________________________________________________________ City _______________________________________ State ________________ Zip _________________________ Daytime Phone No. ____________________________________

Cardholder acknowledges that the United States District Court will apply the payment amount shown above to the debt(s) represented by the referenced docket number. Cardholder agrees to perform the obligations set forth in the cardholder's agreement with issuer.

_______________________________________________________________ Authorized Signature Date USDCNH-65 (Rev. 4/09)