Free Credit Card Authorization Form - Oklahoma

United States Bankruptcy Court Eastern District of Oklahoma
Credit/Debit Card A uthorization Form Name of Attorney/Participant: I hereby authorize the United States Bankruptcy Court for the Eastern District of Oklahoma to charge the following credit/debit card for payment of fees and other cou rt related matters.

U
Visa

Type of Card

Credit Card Number and Exp iration Date Please include: V code on back of the card in italics CC# CC# Please include: CID C ode by expiration date 4-digits CC# CC# CC# CC# CC#

MasterCard Am erican Express

Visa D ebit Card Discover Card Diner's Club C ard MasterCard Debit Card Please Prin t: Nam e on Ca rd Address: City: State: Zip Code: Phon e Num ber: Please indicate if this information is:

New s `

Updated `

This form will be kept on file in the Clerk's O ffice and sh all remain in effect until specifically revoked in writing. It is the responsibility of the cardhold er named herein to notify the C lerk's Office of the new expiration date when a credit card has been renewed, canceled or revoked. This information will be securely maintained in the Clerk's Office. In the event the charge against this account is denied, you will be notified immediately to make payment in cash, money order or certified check. Any abuse of this privilege may result in your removal from the credit card program. Signature_______________________________________________ Date__________________ Title_________________________________________________________________________ Please return completed form to: U.S. Bankruptcy Court, Financial Dept., P.O. Box 1347, Okmulgee, OK 74447

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