United States District Court Northern District of Iowa Credit Card A uthorization Form INSTR UC TIO NS: Please type or print. Mail completed and signed form to: U.S. District Court, Financial Department, 101 First Street SE Cedar Rapids, IA 52401 Firm / Company: ______________________________________________ Phone number: ___________________________ Credit Card Type: VISA Card Holder Name: ______________________________________________ Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date: __ __ / __ __ (MM/YY) Security Code: __ __ __ __ Credit Card Statement Mailing Address: ( Please list the address (Please list the address to which your statements to which your STATEMENTS are sent) are sent) MasterCard Discover Am erican Express ___ ___ ___ ______________________________________________ (Street address or P.O. Box) _______________________, __ __ Zip: __ __ __ __ __ (City, State & Zip) I acknowledge that the above information is accurate and that I am an authorized signer on the account. I hereby authorize the United States District Court for the Northern District of Iowa to charge to the above credit card account any and all court imposed fees, including but not limited to: filing fees, pro hac vice fees, attorney admission fees and special assessments. Date: ________________________ __________________________________ Signature __________________________________ Print Name This form , which w ill be kept on file in the Clerk’s Office, shall remain in effect until specifically revoked in w riting. It is the responsibility of the attorney/firm n amed above to no tify the Clerk ’s Office of the new expiration date when a credit card has been renewed, or if a card has been canceled or revoked. American LegalNet, Inc. www.USCourtForms.com