FORM B 3/12/03 United States Bankruptcy Court of Nebraska Credit/Debit Card Authorization Form Name of Attorney/Participant hereby authorizes the United States Bankruptcy Court for the District of Nebraska to charge the following credit/debit card for payment of fees and other court related matters. G G G G G G G Visa . . . . . . . . . V Code ______________ (appears on back of card in italics) MasterCard American Express . . .CID Code ____________ (appears by exp date 4 - digits) Visa Debit Card MasterCard Debit Card Discover Card Diner’s Club Card Please Print: Credit Card Number Exp Date Credit Card Number (Secondary, if needed) Exp Date Name on Card Address City State Zip Code Phone Number Please indicate if this information is: [ ] NEW [ ] UPDATED - This form replaces all previous forms Yes No This form will be kept on file in the Clerk’s Office and shall remain in effect until specifically revoked in writing. It is the responsibility of the cardholder named herein to notify the Clerk’s Office of the new expiration date when a credit card has been renewed, cancelled or revoked. In the event the charge against this account is denied, you will be notified immediately to make payment in cash, money order or certified check. Any abuse of this privilege may result in your removal from the credit card program. Signature Date Title Please return completed form to: U.S. Bankruptcy Court, Financial Dept, 111 So 18th Plaza, Ste 1125, Omaha, NE 68102 American LegalNet, Inc. www.USCourtForms.com