Authorization For Payment Of Filing Fees By Credit Card

United States Bankruptcy Court Middle District of Louisiana 707 Florida Street, Room 119 Baton Rouge, LA 70801 Monica M. Menier Clerk of Court Telephone: (225)346-3333 AUTHORIZATION FOR PAYMENT OF FILING FEES BY CREDIT CARD I, , authorize the Clerk of the U.S. Bankruptcy Court for the Middle District of Louisiana to charge the following credit card for payment of filing fees in cases and proceedings that I file in this court. I certify that this is my credit card account and that my signature is the authorized signature on the back of the credit card. This authorization will remain in effect until it is rescinded in writing by me. It is my understanding that I will be provided with a credit card receipt and a court receipt for each charge to this account. TYPE OF CARD* CARD NO. EXP. DATE ID NUMBER ***Note: 4 digit code that is located on the front of an American Express card or 3 digit code located on the back of all other credit cards*** STREET ADDRESS ZIP CODE SIGNATURE DATE *VISA, MASTERCARD, DINERS CLUB, DISCOVER, AMERICAN EXPRESS. Updated June 19, 2006 American LegalNet, Inc. www.FormsWorkFlow.com