Free Credit Card Authorization Form - One Time Authorization (*) - Illinois

United States Bankruptcy Court Southern District of Illinois
750 Missouri Avenue East St. Louis, IL 62201 (618) 482-9400 Fax (618) 482-9414

CREDIT CARD AUTHORIZATION FORM ONE TIME AUTHORIZATION
To the Attention of: Name of Debtor(s): Case Number:

I hereby authorize the United States Bankruptcy Court for the Southern District of Illinois to charge the credit card noted below for payment of the fees, costs and expenses which are listed below. I certify that I am an authorized user of this credit card. Name: Address: Signature: Daytime telephone number: Information about card: American Express No. Diners Club No. Discover No. MasterCard No. VISA No. Expiration Date: Expiration Date: Expiration Date: Expiration Date: Expiration Date: Date: Zip Code:

Information about the charge: Please check the appropriate box and the amounts: Filing Fee(s) (for new or reopened cases) Motion Fee(s) Conversion Fee Search Fee Copies and certification Appeal Filing Fee(s) Archive File Retrieval Other: Total Charge Please send copies via: Fax E-mail US mail Fax number: E-mail address: Mailing address: $ $ $ $ $ $_____________ $ $ $

You must photocopy your credit card (both sides) and return a copy with this form.