INSTRUCT IONS FOR COMPLET ING FORM: This for m must be typed. The signature field must b e signed by the person whose signature appears on the back of the credit card. If the card is not present, you must photocopy your credit card (BOTH SIDES) and attached the copy to this form. United States Bankruptcy Court - Northern District of Florida CREDIT CARD ONE TIME AUTHORIZATION FORM I hereb y author ize th e U.S. Bankr uptcy Cour t for th e Northern District of F lorid a to charge th e credit car d lis ted below for payment of fees, costs, and expenses as designated on this form. I certify that I am authorized to use this credit card. The U.S. Bankruptcy Court will maintain this form in the court’s safe. Credit Cardholder Name: Signature: Date: Address: Telephone Number: 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.) Account Number: Exp. Date: CHARGE INFORMATION: Please list the appropriate amounts for each applicable charge. Filing Fee (for new cases) $ Motion Fee $ Conversion Fee $ Search Fee $ Copies and Certificates made by court $ Appeal Fee $ File Retrieval from Archives $ Complaint Fee $ Other: $ TOTAL CHARGES: $ 2002 © American LegalNet, Inc.