Free Attorney Credit Card Blanket Authorization Form - California

INSTRUCTIONS FOR COMPLETING FORM: This form can be obtained on our website at www.canb.uscourts.gov by selecting Credit Card Authorization Form. The form may be downloaded, completed and printed using Adobe Acrobat or Adobe Acrobat Reader. You may also use a typewriter to complete this form. The court will not accept handwritten applications. Please mail the executed, original form to Attn: Finance, United States Bankruptcy Court, Post Office Box 7341, San Francisco, CA 94120-7341.

United States Bankruptcy Court for the Northern District of California

Attorney Credit Card Blanket Authorization Form
I hereby authorize the U. S. Bankruptcy Court for the Northern District of California to charge the credit card listed below for payment of fees, costs, and expenses which are incurred by the authorized users listed below. I certify that I am authorized to sign this form on behalf of my law firm. I understand that this information will be securely maintained in the Clerk's Office. Credit Cardholder Name: Signature: ____________________________________________________ Date:

NAMES OF INDIVIDUALS AUTHORIZED TO USE ACCOUNT NUMBER LISTED BELOW:
(Include cardholder name, if authorized user)

Name _______________________________________________ _______________________________________________ _______________________________________________ Law Firm Name:
(If sole practitioner, type in your name)

BAR ID

Address:

Name of Person to Whom Receipts Should be Mailed: Telephone Number: _________________________ Credit Card Account Number: __ __ __ __ __ __ __ __ __ __ __ __ __ CARD TYPE (Please check one) : Expiration Date (MM/YY):__ __ / __ __

o American Express o

Diner's Club

o

Discover

o

MasterCard

o

VISA

Please check only the locations below where you will be filing & mail the ORIGINAL to the Finance & Procurement Division. Copies will be provided by the court to all other divisions.

o

Oakland Division

o

San Francisco Division

o

San Jose Division

o

Santa Rosa Division

This form will be kept on file in the Clerk's Office and will remain in effect until the expiration of the credit card account. Applicants may also revoke this form by submitting a written request to the above address. A new application must be submitted if information such as the list of authorized users and the credit card account's expiration date is amended. The applicant must also submit a written notification to the court if their credit card was canceled, lost or stolen. COURT USE ONLY: Original maintained in the Finance & Procurement Division of the court. Mailed copies on _______ to:
(date)

o Oakland

o San Francisco

o

San Jose

o

Santa Rosa
(Rev. 3/28/01)