(revised 05/15/13) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF MISSISSIPPI NOTIFICATION TO CHARGE CREDIT CARD ON FILE Firm/Attorney's Name:______________________________________________________ If more than one card on file please indicate which card to be used: Visa_______MasterCard______American Express_______Discover______Diner's Club______ CASE NUMBER (IF ANY):_________________________ 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