United States Bankruptcy Court Southern District of Illinois 750 Missouri Avenue East St. Louis, IL 62201 (618) 482-9400 Fax (618) 482-9414 CREDIT CARD AUTHORIZATION FORM ONE TIME AUTHORIZATION To the Attention of: Name of Debtor(s): Case Number: I hereby authorize the United States Bankruptcy Court for the Southern District of Illinois to charge the credit card noted below for payment of the fees, costs and expenses which are listed below. I certify that I am an authorized user of this credit card. Name: Address: Signature: Date: Daytime telephone number: Zip Code: Information about card: □ □ □ □ □ American Express No. Diners Club No. Discover No. MasterCard No. VISA No. Expiration Date: Expiration Date: Expiration Date: Expiration Date: Expiration Date: Information about the charge: Please check the appropriate box and the amounts: □ □ □ □ □ □ □ □ Filing Fee(s) (for new or reopened cases) Motion Fee(s) Conversion Fee Search Fee Copies and certification Appeal Filing Fee(s) Archive File Retrieval Other: Total Charge $ $ $ $ $ $_____________ $ $ $ Please send copies via: □ Fax Fax number: □ E-mail E-mail address: □ US mail Mailing address: You must photocopy your credit card (both sides) and return a copy with this form. American LegalNet, Inc. www.FormsWorkflow.com