IN THE _____ JUDICIAL CIRCUIT COURT, ___________________________, MISSOURI Request to Establish or Modify Debit Account This form can be used to establish a new debit account with the court or to modify an existing account already established with the court. This form must be filed with the circuit clerk of the court in each county where you wish to establish or modify a debit account. The debit account MUST have funds prior to using the account. Please select one: I would like to establish a new debit account with the court. I need to modify an existing debit account. Account Owner: Contact Person: Check here if this is a modification. Minimum Account Balance: Email a notification when balance falls below minimum account balance: Yes No Email address to send notification to: Court Debit Account Name (required for a modification) Check here if this is a modification. Check here if this is a modification. Authorized Users for Debit Account Name User # 1 User # 2 User # 3 User # 4 User # 5 User # 6 User # 7 User # 8 User # 9 User # 10 (If necessary, attach additional sheets.) Missouri Bar Number For Modifications Add Delete Prepared by: Email Address: Date: Phone Number: OSCA (07-14) GN205 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com