Request For Credit Card Payment Via Telephone-Mail
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Request For Credit Card Payment Via Telephone-Mail Form. This is a Massachusetts form and can be use in District Court Federal.
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Tags: Request For Credit Card Payment Via Telephone-Mail, Massachusetts Federal, District Court
Clerk, US District Court
District of Massachusetts
1 Courthouse Way, Suite 2300
Boston, MA 02210
(617) 748-9143 (cashier)
(617) 748-9096 (fax)
Attention: Cashier
Request for Credit Card Payment via Telephone/Mail
Visa
MasterCard
Discover
Diners Card
Expiration Date
Credit Card Number
American Express
Expiration Date
Credit Card Number
Four Digit ID# for American Express
Purchase Amount
$
(Exact Amount or Not to Exceed)
Name as it appears on Card:
Billing Address:
Do Not Use a PO Box
City
State
Zip Code
Contact Name:
Telephone Number:
Authorized Signature:
Printed Name of Signer:
Reason for Payment:
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