INSTRUCTIONS FOR CO MPLETING FORM : This form must be typed. It is the responsibility of the cardholder to notify the court if a card has been canceled o r stolen. This form will remain in effect until the expira tion date or specifica lly revoked in writing. A ha ndwritten signa ture is required on this form. United States Bankruptcy Court - Northern District of Florida CREDIT CARD BLANKET 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 incurred by the authorized users listed below. I understa nd that when a pleading requiring a fee is received without the fee, the court will automatically charge the account number listed on this form. I cer tify that I am authorized to sign this form on behalf of my law firm. Credit Cardholder Name: Signature: Date: NAMES OF AUTHORIZED USERS: List names of individuals who sign petitions/pleadings (include cardholder name, if applicable). It is not necessary to list any other individuals. Law Firm Name: (If sole practitioner, type your name) Address: Contact Person: Telephone Number: Account Number: Expiration Date: CARD TYPE: (Check card type below) _____ MasterCard ______VISA _____Discover _____American Express* _____Diners Club **American Express ID Number ______ (T his four digit number is printed on your card above the embossed account number.) This form will be maintained in the court’s safe. 2002 © American LegalNet, Inc.