Credit Card Collection Authorization Form {2}

COUNTY CLERK, _______________ COUNTY CREDIT CARD COLLECTION AUTHORIZATION FORM [Electronic Filing] Name hereby authorizes the County Clerk of _________________ County to charge the following credit card number(s) for payment of filing fees and other expenses relating to papers filed by electronic means. (N.B. At present, we only accept Master Card and Visa Cards.) PLEASE PRINT: Master Card No.: Visa Card No.: Exp. Date: Exp. Date: Name as it appears on card: Cardholder's mailing address: City: Business Phone No.: State: Zip Code: Fax No.: In the event the charge against this account is denied, you will be notified immediately to make payment in cash, money order or certified check. This authorization form will be kept on file in the County Clerk's office and shall remain in effect until specifically revoked in writing. It will be maintained in a separate file from the court papers and will not be available to the public. It is the responsibility of the individual/firm/company named herein to notify the County Clerk's office of the new expiration date when a credit card has been renewed, or if a card has been canceled or revoked. Signature: For official use only Identification No.: Date Received: Date: UCS Electronic Filing Form #2: Credit Card Collection Authorization 2002 © American LegalNet, Inc.