VISA/MASTERCARD AUTHORIZATION FORM I hereby authorize payment in the amount shown below to my VISA/MasterCard/Discover account. Case No. (if known) ____________________ Defendant’s name (please print) ________________________________________ I hereby authorize a one-time payment in the amount shown below to my VISA/MasterCard/Discover account. I hereby authorize my court-ordered monthly payment in the amount of $____________ to be charged to my MasterCard/VISA/Discover account on the 3rd Wednesday of each month. [Applies only to cases that have been heard in court and the Judge/Magistrate authorized a monthly payment plan.] VISA/MASTERCARD Account Number Expiration Date Authorized Amount $ Phone Number (_______) _______________ Signature ________________________________ Name of Cardholder ________________________________ (Please Print) FAX the completed form to (419) 352-9407, 24 hours a day. ADDITIONAL INSTRUCTIONS FOR PAYMENT OF A NEW TICKET: You must include a copy (front and back) of your signed ticket, and Proof of Insurance for traffic offenses (if not shown to the officer on the road). American LegalNet, Inc. www.FormsWorkflow.com