Free Credit Card Authorization Criminal Debt - South Carolina

UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA
CREDIT CARD AUTHORIZATION FORM FOR CRIMINAL DEBT PAYMENTS

I hereby authorize the United States District Court for the District of South Carolina to charge the credit card listed below for payment of criminal debt related expenses upon my request via telephone.

Credit Cardholder Name:_________________________________________________________ Address:______________________________________________________________________ Telephone Number:_____________________________ Fax Number:_____________________ Driver's License Number:__________________________Driver's License State:____________ Signature:__________________________________________ Date:____________________

Card Type (Visa, Mastercard, Discover, American Express, Diners Club):__________________ Card Number:_________________________________________________________________ Expiration Date:________________ Mail the original of this form to: United States District Court Attn: Larry Long, Financial Administrator 901 Richland Street Columbia, SC 29201

Note: A copy of the cardholder's driver's license or other identification along with a copy of both sides of the referenced credit card must be returned with this form. This form will be stored in the court's vault and will remain in effect until the cardholder specifically revokes it in writing. It is the responsibility of the cardholder named above to submit a new form and notify the court when: 1) the credit card has been renewed resulting in a new expiration date; and 2) a card has been revoked, canceled, or stolen.

To charge a criminal debt payment to your credit card, call our Columbia office at (803) 253-3137 (8:30 AM - 4:30 PM, Monday - Friday only).