CCAF 06/10 UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF LOUISIANA CREDIT/DEBIT CARD ONE-TIME AUTHORIZATION FORM I hereby authorize the United States Bankruptcy Court for the Western District of Louisiana to charge the following bank card number for payment of filing fees and other court related expenses as designated on this form. Name as it appears on Card: Signature of Cardholder: ______________________________________ Date: _______________________ Name of Law Firm/Business: Billing Address: (Street, P.O.Box, Other) (City, State, Zip Code) Telephone Number: Fax Number: CARD INFORMATION ACCOUNT NUMBER: EXPIRATION DATE:  American Express  Visa CHARGE INFORMATION: CASE NUMBER  Master Card  Discover  Diners Club Please list the appropriate amounts for each applicable charge. DEBTOR NAME FILING/SERVICE FEE AMOUNT ______________ ________________________________ ______________________ $______________ ______________ ________________________________ ______________________ $______________ ______________ ________________________________ ______________________ $______________ ______________ ________________________________ ______________________ $______________ ______________ ________________________________ ______________________ $______________ TOTAL CHARGES 0.00 $______________ Court Use Only: American LegalNet, Inc. www.FormsWorkFlow.com