Free Credit Card Authorization Form - New Jersey

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW JERSEY CREDIT CARD AUTHORIZATION FORM

I hereby authorize the U.S. District Court for the District of New Jersey to charge the credit card listed below for payment of fees, costs and expenses which are incurred by the authorized user(s) listed below. I certify that I am authorized to sign this form on behalf of my law firm. I understand that this information will be securely maintained in the Clerk's Office. NOTE: This form is NOT required for payment of filing fees for complaints, notices of removal or notices of appeal efiled with the Court via ECF and Pay.gov. New Applicant Renewal Applicant If this is a renewal application, please provide your court issued account number here: ______________________

Credit Cardholder Name: _________________________________________________________ Signature: _________________________________________ Date: ______________________ (OPTIONAL) NAMES OF INDIVIDUALS AUTHORIZED TO USE ACCOUNT NUMBER LISTED BELOW : Name __________________________________ __________________________________ __________________________________

___________________________________ ___________________________________ ___________________________________

Law Firm Name: _______________________________________________________________ Address: _______________________________________________ _______________________________________________ _______________________________________________ _________________________________ _________________________________ _________________________________ Fax Number: ________________________

Billing Address if Different:

Telephone Number: ______________________

Name of person to whom receipts should be mailed: ___________________________________ Credit Card Account Number:

Expiration Date (MM/YY): / / American Express MasterCard Visa

Card Type (please check only one):

This form will be kept on file in the Clerk's Office and will remain in effect until the expiration of the credit card account. Applicants may also revoke this form by submitting a written request to the address listed below. A new application must be submitted each time there is a change of any information that you have provided within this document. Please supply the Court with written notification if the credit card provided is lost or stolen. Please allow 3-4 weeks for the completion of this application. Mail this application to the attention of: Susan Travis, Office of the Clerk, U.S. District Court, 50 W alnut Street, Newark, NJ 07102

For Court Use Only: Recv'd ____________________ Completed By _______________________________________ Memo: _____________________________________________ Approved Declined

Acct. No.: ___________________________