UNITED STATES BANKRUPTCY COURT DISTRICT OF SOUTH CAROLINA
TEMPORARY AUTHORIZATION FORM I hereby authorize the U. S. Bankruptcy Court for District of South Carolina to charge the credit card listed below for payment of fees, costs, fines, and expenses which are listed below. I certify that I am a person who is authorized to use this credit card. This form has been signed by the person whose signature appears on the back of the credit card and either (1) the card is being presented simultaneously with this form or (2) a copy of the front and back of the credit card is attached hereto. Credit Cardholder Name: Address:
Signature: Daytime Telephone No.:
Date: Fax No.:
CARD INFORMATION: VISA Account No.: Exp. Date: MASTERCARD Acct. No.: Exp. Date: DISCOVER Account Number: ____________________________ Exp. Date: _________ AMERICAN EXPRESS Account Number: ____________________ Exp. Date:________ CHARGE INFORMATION: Please list the appropriate amounts for each applicable charge. Filing Fees (for new cases) Motion Fees Conversion Fee Amendment Fee Search Fee Copies and Certificates made by Court Appeal Fee File Retrieval from Archives Adversary Filing Fee Other: TOTAL CHARGES $ $ $ $ $ $ $ $ $ $ $
If card is not being presented, you must photocopy the creditcard (BOTH SIDES) and attach the copy to this form.