One Time Credit Card Authorization Form
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One Time Credit Card Authorization Form. This is a Arkansas form and can be use in USBC Eastern And Western Federal.
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Tags: One Time Credit Card Authorization Form, Arkansas Federal, USBC Eastern And Western
INSTRUCTIONS FOR COMPLETING FORM:
This form must be typed and can be completed electronically on our website, www.arb.uscourts.gov/forms/ccauthfillable.pdf
.
Press the tab key to advance to each field. A handwritten signature is required. This form must be faxed to 501-918-5520.
United States Bankruptcy Court - Eastern & Western Districts of Arkansas
ONE TIME CREDIT CARD AUTHORIZATION FORM
I hereby authorize the U.S. Bankruptcy Court to charge the credit card listed below for payment of fees,
costs, and expenses which are listed below. I certify that I am a person who is authorized to use this
credit card.
Credit Cardholder Name:
Address:
Signature:
Date:
Daytime Telephone Number:
Fax Number:
CARD INFORMATION
Account Number:
Expiration Date:
CARD TYPE:
**American Express ID Number:
account number.)
(This four digit # is printed on your card above the embossed
CHARGE INFORMATION: Please check the appropriate box and insert the amount to be charged.
Filing fees
Installment Fees
Motion Fees
Conversion Fee
Search Fee
Copies
Certifications
Appeal Fee
Archived File Retrieval
Adversary Fees
Other:
TOTAL TO BE CHARGED
Please list all debtors and case numbers:
What is the reason you are not filing electronically?
Installment
Other (give reason below)
(Version 8/1/03)
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