PAYMENT FORM Complete this form when making a payment in order to satisfy your citation(s). • Mail the yellow citation or a copy with this form to: CLERK OF COUNTY COURTS, TRAFFIC COURTS DIVISION P.O. BOX 02-5450, MIAMI, FL 33102-5450 • You may pay by check, money order, VISA, or MASTERCARD in U.S. funds. Please make check or money order payable to CLERK OF COURTS. Do not send cash. • To avoid late fees and the suspension of your driver’s license your payment must be received in this office WITHIN 30 DAYS of the issue date of the citation. PLEASE PRINT LAST NAME FIRST NAME MIDDLE NAME STREET ADDRESS APT. # CITY ( STATE ZIP CODE ) AREA CODE TELEPHONE NUMBER CITATION NUMBER _______________________ _______________________ _______________________ _______________________ [ ] [ ] Check Money Order $ TOTAL $ AMOUNT PAID ___________________ ___________________ ___________________ ___________________ ___________________ CREDIT CARD INFORMATION Please enter all requested information. We honor only VISA and MASTERCARD. Please charge to (check one): EXPIRATION DATE _____ / ______ [ ] VISA [ ] MASTERCARD Month Year CREDIT CARD NUMBER /___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/ PRINT EXACT NAME APPEARING ON CREDIT CARD AUTHORIZED SIGNATURE CLK/CT 900 REV. 5/03 American LegalNet, Inc. www.USCourtForms.com