Single Transaction Credit Card Authorization Form

UNITED STATED DISTRICT COURT FOR THE DISTRICT OF COLORADO 901 19th Street, Room A105 Denver, Colorado 80294-3589 Voice 303-335-2526 Fax 303-335-2714 SINGLE TRANSACTION CREDIT CARD AUTHORIZATION FORM This form can be used to pay the filing fee for miscellaneous fees or the submission of a sealed case or miscellaneous matter. Please check the appropriate box. This form will only be used for one charge and cannot be used for future charges. A new form must be completed for each charge. Filing fee for a sealed case or miscellaneous matter Case title Email form to: newcases@cod.uscourts.gov Miscellaneous fee for Email form to: codintake@cod.uscourts.gov Please Print Credit Card Information: Full Name on Card Billing Address City State Zip Code Phone Type of Card Card # Exp. Date Card Security Code (3 or 4 digit code on front of card) I hereby authorize the use of this credit card for a one-time charge for the payment noted above. The information will not be used for any other charges. Date Approved by (Signature) (Print Name) /2018 American LegalNet, Inc. www.FormsWorkFlow.com