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Credit Card Authorization Form. This is a Georgia form and can be use in District Court Federal.
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Tags: Credit Card Authorization Form, Georgia Federal, District Court
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
UNITED STATES DISTRICT COURT
:
MIDDLE DISTRICT OF GEORGIA
:
CREDIT CARD AUTHORIZATION FORM
Defendant(s)
:
......................................................
(Name of Company/Firm)
hereby authorizes the United States District for
THE PEOPLE OF THE STATE OF NEW YORK the Middle District of Georgia to charge the
credit card listed below for payment of filing fees and other court related expenses incurred by
TO individuals listed below. I certify that I am authorized to sign the form on behalf of my firm.
the
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
inSignature:______________________________________ Date:__________________________ recessed
room
, on the
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
Card Type (Visa, MasterCard, Discover, American Express, Diners Club)__________________
Card Number:_________________________________________________________________
Expiration Date:___________________________
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
INDIVIDUALS to comply.
result of your failureAUTHORIZED TO USE ABOVE CREDIT CARD ACCOUNT
____________________________________
____________________________________
Witness, Honorable
____________________________________
Court in
County,
day of
Mail the original form to:
, 20
______________________________
______________________________
, one of the Justices of the
______________________________
CLERK, UNITED STATES DISTRICT COURT
POST OFFICE BOX 128 (Attorney must sign above and type name below)
MACON, GA 31202
This form will be stored in the court’s vault for safekeeping purposes and will remain in effect
Attorney(s) for
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; 2) a credit card has been renewed
Office 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.:
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