Credit Card Blanket Authorization

(revised 1/31/06) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF MISSISSIPPI CREDIT CARD ACCEPTANCE FOR PAYMENT OF FILING FEES The United States Bankruptcy Court for the Northern District of Mississippi now accepts credit cards from attorneys for payment of filing fees received through the mail, by messenger, or electronically through the U.S. Treasury Internet Credit Card Program. The court will accept Visa, MasterCard, Discover, American Express, and Diner's Club cards. Acceptance of payment by credit card from debtors is prohibited. Requirements for paying filing fees through the mail by credit card: A Credit Card Blanket Authorization form(with a copy of the front and back of your credit card attached) signed by the cardholder listing all authorized users must be on file with the court. A Notification to Charge Credit Card on File must be submitted with filing. OR A Credit Card One Time Authorization form signed by the cardholder submitted with the filing. You must photocopy your credit card (BOTH SIDES) and attach the copy to this form. These forms are attached. In addition, they will be available on the Court's Internet site (www.msnb.uscourts.gov). RECEIPTS: Cash register and credit card receipts will be returned or mailed to persons making payment by credit card via U.S. Mail if a separate self-addressed, stamped envelope is provided. If you are paying a filing fee in person, please present the credit card to the cashier. Mail original form to: Edna T. Garth, Financial Administrator U.S. Bankruptcy Court Northern District of Mississippi Thad Cochran U.S. Courthouse 703 Hwy. 145 N Aberdeen, MS 39730 Further questions about credit card program, contact Edna T. Garth, Financial Administrator, at (662)319-3559. American LegalNet, Inc. www.FormsWorkFlow.com (revised 12/12/05) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF MISSISSIPPI CREDIT CARD BLANKET AUTHORIZATION (ATTACH A COPY OF THE FRONT AND BACK OF YOUR CREDIT CARD) PLEASE TYPE: Name of Firm:_________________________________________________________________ (If sole practitioner, type your name) Address:______________________________________________________________________ City:______________________________ State:_________________ Zip code:_____________ Telephone Number:_____________________ Contact Person:___________________________ hereby authorizes the United States Bankruptcy Court for the Northern District of Mississippi to charge the following credit card for payment of filing fees (and other fees approved for credit card use in the future) incurred by the authorized users listed below: CHECK ONE (Each Card Requires a Separate Authorization) Visa________ MasterCard_______ American Express________ Discover______ Diners______ CREDIT CARDHOLDER'S NAME:__________________________________________ STATEMENT MAILING ADDRESS: (required) Street or P.O. Box Number: _________________________________________ City:_________________________, State:____________________, Zip Code:_____________ CREDIT CARD # _______________________________ EXPIRATION DATE:___________ AUTHORIZED SIGNATURE:____________________________ DATE:________________ NAME OF INDIVIDUALS AUTHORIZED TO CHARGE TO THIS ACCOUNT: _______________________________ _____________________________ _______________________________ _____________________________ _______________________________ _____________________________ _______________________________ _____________________________ This form will be securely maintained on file in the Clerk's Office and shall remain in effect until specifically revoked in writing. It is the responsibility of the law firm/attorney named herein to notify the Clerk's Office when the information on this form has expired or changed, or if the card has been canceled or revoked. ________________________________________________________________________ FOR COURT USE ONLY: Date Received:__________________________ By:____________________________________ ______________________________________________________________________________ In the event a charge against this account is denied, you will be notified immediately to make payment in cash, money order or check. Any abuse of this privilege may result in your removal from the credit card program. Return Completed Form to: Edna T. Garth, Financial Administrator U.S. Bankruptcy Court, NDMS 703 Hwy 145 N Aberdeen, MS 39730 American LegalNet, Inc. www.FormsWorkFlow.com