Authorization Form
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Authorization Form. This is a Missouri form and can be use in Bankruptcy-District Court Federal.
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Tags: Authorization Form, Missouri Federal, Bankruptcy-District Court
United States District/Bankruptcy Court
Western District of Missouri
AUTHORIZATION FORM
_________________________________________________________________
(All Attorney Name(s) and Firm, attach additional sheets if necessary)
hereby authorizes the United States District/Bankruptcy Court for the Western
District of Missouri to charge the following credit card number for payment
of identified Court-related expenses.
PLEASE TYPE OR PRINT
Visa Number___________________________Exp. Date__________
Mastercard Number_______________________Exp. Date_________
American Express ________________________Exp. Date_________
Discover ____________________________Exp. Date ____________
Name____________________________________________________
Address__________________________________________________
City__________________________State_______Zip Code_________
Telephone Number__________________________________________
Authorized Signatures
Attach additional sheets if necessary.
____________________________
(Signed)
____________________________
(Signed)
___________________________
(Typed)
___________________________
(Typed)
DATE ____________________
This form, which will be kept on file in the Clerk’s Office, shall remain in effect until specifically
revoked in writing. It is the responsibility of the attorneys named herein to notify the Clerk’s
Office, Finance Section of the new expiration date when a credit card has been renewed, if a
card has been canceled or revoked or if a user is no longer authorized on the above card.
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