Clear United States District Court Eastern District of Missouri www.moed.uscourts.gov 314-244-7900 CREDIT/DEBIT CARD AUTHORIZATION FORM I hereby authorize the U.S. District Court for the Eastern District of Missouri to charge the card listed below for payment of fees which are incurred by the authorized users. I certify that I am authorized to sign this form on behalf of my law firm or corporation and /or tha t I am th e pe rson auth orize d to u se th is card . I und ersta nd th at this info rmatio n will be secu rely ma intaine d by the C our t. I also un de rsta nd tha t wh en an initiatin g p etitio n re qu iring a fe e is r ece ived thro ug h th e e lectr on ic co urt filin g sy stem , the Co urt w ill automatically charge the account number listed on the form. New Applicant Renewal Applicant Cardholder Name as it appears on card: Billing Address City/Sta te Card Num ber: Expira tion D ate: Signature of Card Ho lder: Type : Mastercard Date: Visa Discover American Express Other Additional names and signatures of individuals authorized to use account num ber listed above for payment of fees: Print Name: Signature: Law Firm Name: (If sole practitioner, type in your name) Address: Immediate Contact Numb er: Alternate Contact Number: This for m will rem ain in e ffect un til the exp iration d ate is m et or s pec ifically revo ked in writing . It is the ca rdh olde r’s resp ons ibility to submit a new form and notify the court of: (1) any changes to the registered attorney or employee, (2) a new expiration date when a credit card has been renewed, or (3) a card has been revoked, canceled, or stolen. In the eve nt the cha rge aga inst the acco unt is d enie d, yo u will be notified immed iately to m ake pay men t in cas h, mo ney orde r or ch eck. Any abuse of this privilege may result in your removal from the credit card program. Sub mit this for m, with a ph otcop y o f the front and b ack of th e card to : Cashier U.S. District Court - EDMO 111 South 10 th Street, Rm 3.300 St. Louis, MO 63102 No te: C as e relate d fee s m us t hav e a c red it card a utho rization fo rm co mp leted pr ior to the ca rd be ing ac ce pted as pay me nt. FOR COURT USE ONLY Re c’d Entered Date Entered American LegalNet, Inc. www.FormsWorkflow.com