Free Credit Card Authorization for Payment of Fines Form - Arizona

KINGMAN MUNICIPAL COURT
219 N 4TH ST KINGMAN, AZ 86401 928-753-8193 FAX: 928-753-8099 (PLEASE PRINT)

CREDIT CARD AUTHORIZATION FOR PAYMENT OF FINES Cardholder Name: Cardholder Phone #: Credit Card Billing Address: City, State, Zip: Credit Card #: 3 Digit Security Code on Back of Credit Card: Expiration Date: I Authorize the Kingman Municipal Court to Charge the above Credit Card in the Amount of $ Defendant=s Name: Case Number / Citation #: Cardholder Signature: Date:

When your fax or mail this form to the Court you must also include: 1. A copy of the front and back of the credit card 2. A copy of your picture identification

Once you have faxed the information, it is your responsibility to contact the Court to make sure that we received your information and that it is legible. If the Court is unable to clearly read the information, you may be asked to fax it again.