Credit Card Authorization Form For Criminal Debt Payment
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Credit Card Authorization Form For Criminal Debt Payment Form. This is a Kansas form and can be use in District Court Federal.
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Tags: Credit Card Authorization Form For Criminal Debt Payment, Kansas Federal, District Court
UNITED STATES DISTRICT COURT
DISTRICT OF KANSAS
CREDIT CARD AUTHORIZATION FORM FOR
CRIMINAL DEBT PAYMENT
I hereby authorize the United States District Court for the District of Kansas to charge the credit
card listed below for criminal debt payments upon my request via telephone.
Credit Cardholder Name:
Address:
Telephone Number:
Driver’s License Number:
Signature:
Fax Number:
Driver’s License State:
Date:
Card Type (Visa, Mastercard, Discover, American Express, Diners Club)
Card Number:
Expiration Date:
Security Code:________________
Mail the original of this form to:
CLERK, UNITED STATES DISTRICT COURT
FINANCIAL DEPARTMENT
500 STATE AVE., RM 259
KANSAS CITY, KS 66101
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.
This form will be stored in the court’s vault 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; 2) a credit card has been renewed
resulting in a new expiration date; and 3) a card has been revoked, canceled, or stolen.
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