UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NORTH CAROLINA CREDIT CARD AUTHORIZATION FORM INSTRUCTIONS: Please type or print. Mail completed and signed form to: “CONFIDENTIAL United States Bankruptcy Court Eastern District of North Carolina ATTN: FINANCIAL ADMINISTRATOR Post Office Box 2807 Wilson, NC 27894-2807" FIRM/COMPANY: Phone Number: Credit Card Type: Visa MasterCard Discover American Express Diners Club Card Holder Name: Credit Card Number: Expiration Date: / - - (MM/YY) Credit Card Statement Mailing Address: (Please be sure to list the address where the credit card company sends your statements). Street Address or P. O. Box City, State & Zip I acknowledge that the above information is accurate and that I am an authorized signer of the account. I hereby authorize the United States Bankruptcy Court for the Eastern District of North Carolina to charge the above credit card account for court filing fees incurred by me, my firm or company. Date: Signature Print Name 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 attorney/firm named herein to notify the Clerk’s Office, Financial Administrator, of the new expiration date when a credit card has been renewed, or if a card has been canceled or revoked. American LegalNet, Inc. www.USCourtForms.com