On-Line Credit Card Fee Refund Request Form
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On-Line Credit Card Fee Refund Request Form. This is a Texas form and can be use in Bankruptcy Court Federal.
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Tags: On-Line Credit Card Fee Refund Request Form, Texas Federal, Bankruptcy Court
UNITED STATES BANKRUPTCY COURT
WESTERN DISTRICT OF TEXAS
ON-LINE CREDIT CARD FEE REFUND REQUEST FORM
I hereby request the U. S. Bankruptcy Court for the Western District of Texas to refund
the credit card listed below for payment of fees paid in error via the CM/ECF on-line
credit card payment system.
CREDIT CARDHOLDER NAME: _______________________________________________
BILLING ADDRESS :
SIGNATURE:
____________________________________________________
____________________________________________________
____________________________________________________
__________________________________________DATE:___________
DAYTIME TELEPHONE NUMBER :____________________
CARD INFORMATION:
CARD TYPE
ACCOUNT NUMBER
EXP. DATE
CM/ECF POSTED RECEIPT NUMBER AND DATE: _________________________
Attach a copy of the receipt printout given upon payment.
AMOUNT TO BE REFUNDED
$
CASE #
BRIEF EXPLANATION FOR REFUND ____________________________________
___________________________________________________________________
MAIL TO:
or fax at
U.S. BANKRUPTCY COURT
ANNETTE ANDERSON, FINANCE
P O BOX 1439
SAN ANTONIO, TX 78295
210-472-6215
FOR OFFICIAL COU RT US E ONLY
APPROVED BY:
DATE:
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