COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : UNITED -against- : Plaintiff(s) Calendar No. JUDICIAL SUBPOENA STATES DISTRICT COURT : DISTRICT OF SOUTH CAROLINA : : CREDIT CARD AUTHORIZATION FORM FOR CRIMINAL DEBT PAYMENTS Defendant(s) : ...................................................... I hereby authorize the United States District Court for the District of South Carolina to charge the credit card listed below for payment of criminal debt related expenses upon my request via telephone. THE PEOPLE OF THE STATE OF NEW YORK Credit Cardholder Name:_________________________________________________________ TO Address:______________________________________________________________________ Telephone Number:_____________________________ Fax Number:_____________________ GREETINGS: Driver’s License Number:_________________________ Driver’s License State:____________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Signature:__________________________________________ Court Date:____________________ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Card Type (Visa, Mastercard, Discover, American Express, Diners Club):_________________ Card Number:_________________________________________________________________ Expiration Date:________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a District Court of $50 and all damages sustained as a Mail the original of this form to: United States maximum penalty result of your failure to comply. Attn: Larry Long, Financial Administrator Witness, Honorable Court in County, 901 Richland Street Columbia, SC 29201 day of , one of the Justices of the , 20 Note: A copy of the cardholder’s driver’s license or other identification along with a copy of both sides of the referenced credit card must be returned with this form. (Attorney must sign above and type name below) This form will be stored in the court’s vault and will remain in effect until the cardholder specifically revokes it in writing. Attorney(s) for It is the responsibility of the cardholder named above to submit a new form and notify the court when: 1) the credit card has been renewed resulting in a new expiration date; and 2) a card has been revoked, canceled, or stolen. Office and P.O. Address To charge a criminal debt payment to your credit card, call our Columbia office at (803) 253-3137. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com