United States Bankruptcy Court Southern District of Illinois
750 Missouri Avenue East St. Louis, Illinois 62201 (618)-482-9400 Fax (618) 482-9414
CREDIT CARD BLANKET AUTHORIZATION FORM I hereby authorize the United States Bankruptcy Court for the Southern District of Illinois to charge the credit card noted below for payment of fees, costs and expenses which are incurred by myself or any member or employee of the law firm, partnership or professional corporation stated below. I certify that I am authorized to sign this form on behalf of my law firm. This form must be signed by the person whose signature appears on the back of the credit card. Name: __________________________________ Signature: __________________________________ Date: ______________________
Law Firm Name: ___________________________________________________________ (sole practitioner type in your name) Address: _________________________________________________________________ _________________________________________________________________ Name of Person to whom receipts should be sent: ________________________________ Telephone Number: ________________________________________________________
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American Express No. _________________________ Diners Club No. _____________________________ Discover No. ________________________________ MasterCard No. ______________________________ VISA No. __________________________________
Expiration Date: __________ Expiration Date: __________ Expiration Date: __________ Expiration Date: __________ Expiration Date: __________
Please pay for any charges by charging them to this credit card and sending the firm an itemized receipt at the time of each transaction.
This form will be kept on file in the Clerk's office and will remain in effect until specifically revoked in writing and/or the expiration date of the card has passed. It is the responsibility of the law firm named above to complete a new credit card blanket authorization when a credit card has been renewed or to notify the court if the card has been revoked, canceled or stolen.
You must photocopy your credit card (both sides) and attach the copy to this form.