INSTRUCTIONS FOR COMPLETING FORM: This form must be typed. The signature field must be signed by the person whose signature appears on the back of the credit card. If you are mailing or faxing this form, you must photocopy your credit card (BOTH SIDES) and include the copy with this form. United States Bankruptcy Court - Northern District of Florida CREDIT CARD ONE TIME AUTHORIZATION FORM I hereby authorize the U.S. Bankruptcy Court for the Northern District of Florida to charge the credit card listed 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. Card Holder Name: Signature: Date: Address: Telephone:CARD TYPE: MasterCard VISA Discover American Express* * American Express ID Number:(This four digit number is printed on your card above the embossed account number.) Account Number: Expiration Date: CHARGE INFORMATION: Please list the appropriate amounts for each applicable charge. The current fee schedule is available on the court's website at http://www.flnb.uscourts.gov/court-resources/filing-fees. Filing Fee (for new cases) $ TOTAL CHARGES $ Other: $ Complaint Fee $ File Retrieval from Archives $ Appeal Fee $ Copies & Certifications made by Court $ Search Fee $ Conversion Fee $ Motion Fee $ The form and photocopy of the credit card (both sides) may be mailed to the Tallahassee office located at 100 E. Park Ave., Ste. 100, Tallahassee, FL 32301 or these items may be faxed. Contact the Clerk's Office at (850) 521-5001 or (866) 639-4615 to obtain the fax number.FLNB Local Form A-1 (Rev. 12/18) American LegalNet, Inc. www.FormsWorkFlow.com