(revised 05/15/13 ) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF MISSISSIPPI CREDIT CARD ONE TIME AUTHORIZATION FORM (A COPY OF THE FRONT AND BACK OF YOUR CREDIT CARD MUST BE ATTACHED) I hereby authorize the U.S. Bankruptcy Court for the Northern District of Mississippi to charge the credit card listed below for payment of fees which are listed below. I certify that I am authorized to use this credit card. CREDIT CARD INFORMATION: CREDIT CARD TYPE:________________________________________ (VISA, MASTERCARD, AMERICAN EXPRESS DISCOVER, DINER'S CLUB) ACCOUNT NUMBER:___________________________________ EXP. DATE:__________ CREDIT CARDHOLDER'S NAME:______________________________________________ CARDHOLDER'S STATEMENT ADDRESS: Street or P.O. Box Number: ________________________________________________ City_____________________, State___________________, Zip Code (required)___________ Signature:___________________________________ Date:______________________ DAYTIME TELEPHONE NO.:___________________________ CASE NO:___________________, ADV. NO.:________________________ DEBTOR'S NAME:____________________________________________ FILING FEE TO BE CHARGED: PETITIONS (Chpt. 7 = $306, Chpt 13 = $281, Chpt 11 = $1,213, Chpt 12 = $246) MOTIONS: (Divide Chpt 7=$306, Chpt 13=$281, Chpt 11=$1,213, Chpt 12 = $246; Stay, Abandonment, withdrawal = $176; Reopen - Chpt. 7 = $260, 13 = $235, 11 = $1,167, 12 = $200) $__________ $__________ CONVERSION FEES (from Chpt 11 to 7 = $15, from Chpt 12 to 7 = $60, from Chpt 13 to 7 = $25, from Chpt 12 to 13 =$35, to Chpt. 11 by Chpt 7 debtor =$922, by 13 debtor = $932) $__________ APPEAL/CROSS APPEAL ($298) AUTHORIZED DIRECT APPEAL/CROSS APPEAL ($157) AMENDMENTS ($30) COMPLAINT ($293) OTHER $__________ $__________ $__________ $__________ $__________ TOTAL CHARGES TO CREDIT CARD $__________ SIGNATURE OF AUTHORIZED USER:_______________________________________ Acceptance of payment by credit card from debtors is prohibited. American LegalNet, Inc. www.FormsWorkFlow.com