Credit Card Collection Authorization
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Credit Card Collection Authorization Form. This is a New York form and can be use in Filing By Electronic Means Statewide.
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Tags: Credit Card Collection Authorization, 2, New York Statewide, Filing By Electronic Means
COUNTY CLERK, _______________ COUNTY
CREDIT CARD COLLECTION
AUTHORIZATION FORM
[Facsimile filing]
Name
hereby authorizes the County Clerk of _________________ County to charge the following
credit card number(s) for payment of filing fees and other court-related expenses. (N.B. The
Monroe County Clerk only accepts Master Card and Visa Cards.)
PLEASE PRINT:
Master Card No.:
Exp. Date:
Visa Card No.:
Exp. Date:
Discover Card No.:
Exp. Date:
American Express No.:
Exp. Date:
Diner’ Club No.:
s
Exp. Date:
Name as it appears on card:
Cardholder’ mailing address:
s
City:
Business Phone No.:
State:
Zip Code:
Fax No.:
*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.
This form will be kept on file in the County Clerk’ office and shall remain in effect until
s
specifically revoked in writing. It will be maintained in a separate file from the court papers and
will not be available to the public. It is the responsibility of the individual/firm/company named
herein to notify the County Clerk’ office of the new expiration date when a credit card has been
s
renewed, or if a card has been canceled or revoked.
Signature:
Date:
For official use only
Identification No.:
Date Received:
Fax Filing Form #2: Credit Card Collection Authorization
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