Authorization For Payment Of Filing Fees By Credit Card
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Authorization For Payment Of Filing Fees By Credit Card Form. This is a Louisiana form and can be use in Bankruptcy Court Federal.
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Tags: Authorization For Payment Of Filing Fees By Credit Card, Louisiana Federal, Bankruptcy Court
United States Bankruptcy Court
Middle District of Louisiana
707 Florida Street, Room 119
Baton Rouge, LA 70801
Monica M. Menier
Clerk of Court
Telephone: (225)346-3333
AUTHORIZATION FOR PAYMENT OF
FILING FEES BY CREDIT CARD
I,
, authorize the Clerk of the U.S. Bankruptcy Court
for the Middle District of Louisiana to charge the following credit card for payment of filing fees
in cases and proceedings that I file in this court. I certify that this is my credit card account and
that my signature is the authorized signature on the back of the credit card. This authorization
will remain in effect until it is rescinded in writing by me.
It is my understanding that I will be provided with a credit card receipt and a court receipt for
each charge to this account.
TYPE OF CARD*
CARD NO.
EXP. DATE
ID NUMBER
***Note: 4 digit code that is located on the front of an American
Express card or 3 digit code located on the back of all other credit
cards***
STREET ADDRESS
ZIP CODE
SIGNATURE
DATE
*VISA, MASTERCARD, DINERS CLUB, DISCOVER, AMERICAN EXPRESS.
Updated June 19, 2006
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