COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : UNITED STATES DISTRICT COURT : MIDDLE DISTRICT OF GEORGIA : Defendant(s) : ...................................................... CREDIT CARD AUTHORIZATION FORM FOR CRIMINAL DEBT PAYMENT THE PEOPLE OF THE STATE OF NEW YORK I hereby authorize the United States District for the Middle District of Georgia to charge the credit card listed below for criminal debt payments upon my request via telephone. TO Credit Cardholder Name:_________________________________________________________ GREETINGS: Address:______________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Telephone , the HonorableNumber:________________________ Fax Number:__________________________ at the Court located at County of inDriver’s License on the room , Number____________________Driver’s License State___________________ recessed day of , 20 , at o'clock in the noon, and at any or adjourned date, to testify and give evidence as a witness in this action on the part of the Signature:______________________________________ Date:__________________________ Card Type (Visa, MasterCard, Discover, American Express, Diners Club)__________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Card Number:_________________________________________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Expiration Date:___________________________ result of your failure to comply. Witness, Honorable Mail the Court in original form to: County, , one of the Justices of the CLERK, UNITED,STATES DISTRICT COURT day of 20 POST OFFICE BOX 128 MACON, GA 31202 (Attorney must sign above and type name below) Note: A copy of the cardholder’s driver’s license or other identification along with a copy of both sides of the referenced credit card must be returned with this form. Attorney(s) for This form will be stored in the court’s vault for safekeeping purposes and will remain in effect until the cardholder specifically revokes it in writing. It is the responsibility of the cardholder and/or firm named above to submit a new form and notify the court when 1) authorized users change;Officecredit card has been renewed 2) a and P.O. Address resulting in a new expiration date; and 3) a card has been revoked, canceled or stolen. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com