INSTRUCTIONS FOR COMPLETING FORM: Press the tab key to advance to each field. A new form must be submitted to the court upon any change to: name, address, phone number, authorized user, account number, expiration date, etc. It is the responsibility of the cardholder to notify the court if a card has been canceled or stolen. This form will remain in effect until the card's expiration date or specifically revoked in writing. A handwritten signature is required on this form. United States Bankruptcy Court - Eastern District of Kentucky CREDIT CARD BLANKET AUTHORIZATION FORM I hereby authorize the U.S. Bankruptcy Court, Eastern District of Kentucky, to charge the credit card listed below for payment of fees, costs, and expenses which are incurred by the authorized users listed below. I understand that when a pleading requiring a fee is received from me without the fee, the court will automatically charge the account number listed on this form. Initial installment payments will be charged at the time of filing the petition. The charging of subsequent installment payments will require ECF notification, prior to the payment due date. I certify that I am authorized to sign this form on behalf of my law firm. Credit Cardholder Name: Signature: ______________________________________ Date: NAMES OF AUTHORIZED USERS: List names of individuals who sign petitions/pleadings (include cardholder name, if applicable). It is not necessary to list any other individuals. Law Firm: Mailing address for bank card statement: (If sole practitioner, type your name) Contact Person: Telephone Number: ( ) E-mail address: Name and address of person to whom receipts should be mailed: Account Number: CARD TYPE: (Check card type below) MasterCard VISA Discover **American Express ID Number: Expiration Date: American Express** (This four digit # is printed on your card above the embossed account number.) This information is When complete, please print this form, sign it, mark it CONFIDENTIAL and mail to: Financial Manager, US Bankruptcy Court, Eastern District of Kentucky, P.O. Box 1111, Lexington, KY 40588-1111 (Rev.02/22/10) American LegalNet, Inc. www.FormsWorkFlow.com NEW or UPDATED