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: American LegalNet, Inc. www.FormsWorkflow.com