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United States District Court Eastern District of New York

Credit Card Blanket Authorization Form
I hereby authorize the United States District Court for the Eastern District of New York to charge the main credit card or the alternate credit card listed below for payment of fees, costs, and expenses which are incurred by myself or any member or employee of the law firm, partnership, or professional corporation stated below. I certify that I am authorized to sign this form on behalf of my law firm. (Please indicate which card is to be the main card and the alternate card)

MasterCard No. Visa Card No.

Exp. Date: Exp. Date:

Credit Cardholder's Name:
NAMES OF INDIVIDUALS AUTHORIZED TO USE, ACCOUNT NUMBERS LISTED FOR PAYMENT OF FEES, COSTS AND EXPENSES (use rider if necessary):

Cardholder's Mailing Address City: Law Firm Name:
(If sole practitioner, write your name)

State:

Zip Code:

Address: Phone No:

Fax No:

This form will be kept on file in the Clerk's Office and will remain in effect until specifically revoked in-writing. It is the responsibility of the law firm/company named above to submit a new form and notify the court of any changes to authorized users, a new expiration date when a credit card has been renewed, or a card has been revoked, cancelled, or stolen.

Signature:

Date:

* Note: The card indicated above as the main card will be used for all transactions with this court unless otherwise specified by the authorized user. ** PLEASE RETURN THIS COMPLETED FORM TO THE FINANCIAL DEPARTMENT, U.S. DISTRICT COURT, E.D.N.Y., 225 CADMAN PLAZA EAST, BROOKLYN, NEW YORK 11201