UNITED STATES DISTRICT COURT DISTRICT OF MINNESOTA REQUEST FOR CREDIT CARD PAYMENT I hereby authorize the United States District Court for the District of Minnesota 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: Name of Law Firm/Business: Credit Card Billing Address: Date: Contact Person Name: CARD INFORMATION Account Number: Phone Number: Exp. Date: [ ]Visa [ ]Discover [ ]American Express [ ] Diners [ ] Mastercard Reason for Payment Short Case Title: (Required) Transaction (new case, appeal, copies, etc.) Documents Sent Enclosed In advance on Will be sent on _________ by E-mail Mail Courier Enclosed In advance on Will be sent on _________ by E-mail Mail Courier Enclosed In advance on Will be sent on _________ by E-mail Mail Courier Enclosed In advance on Will be sent on _________ by E-mail Mail Courier Amount $ $ $ $ $ TOTAL CHARGES Fax this form to one of the Clerk's Offices Between the hours of 8am ­ 5pm CST: Minneapolis (612) 664-5033 St. Paul (651) 848-1109 Duluth (218) 529-3505 Fergus Falls (218) 739-5325 NOTE: As of January 1, 2013, the Court will no longer accept credit card payments by facsimile for any purpose. Credit cards may be used to pay fees through CM/ECF and pay.gov. American LegalNet, Inc. www.FormsWorkFlow.com