UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF TEXAS CREDIT CARD AUTHORIZATION FORM Attention: INTAKE Please complete the Copies/Certifications section and authorize the transaction by your signature in the Authorization section. Submit the completed form to the appropriate division using the instructions found at the end of the form. COPIES/CERTIFICATION You may receive copies and document certifications via email. Alternatively, you may receive copies less than 100 pages (but not certifications) via fax. If you do not provide an email address or fax number, the document(s) will be mailed to you. If the document(s) is to be sent to an address other than the billing address, please indicate the mailing address below. Provide sufficient detail to make your needs clear and include the document number(s) and title of document(s) requested to be copied or certified. Total Number of Pages:*___________ @ $ 0.50 per page = _______ $ 0.00 Number of Certified Documents:*____ For a total of ______________ $ 0.00 @ $ 9.00 each = $ 0.00 _______ * If you do not designate the number of pages, you will be billed for all pages of the document. AUTHORIZATION (Name of Individual, Company or Firm) hereby authorizes the United States District Court for the Northern District of Texas to charge the bank credit card listed below for payment for the aforementioned copies and/or certifications. American Express Amex ID Code # (4 digits): Diner's Club Discover Credit card number: Visa Master Card Expiration date: Name (as it appears on the card): Billing Address: City: State: Zip code: Phone (Required): Printed Name of Authorized Card User: Signature of Authorized Card User: Date: American LegalNet, Inc. www.FormsWorkFlow.com SUBMITTING THE FORM Although you may complete most of this fillable form on our website, the authorized credit card user must sign the form immediately above. You may either scan and email the form, or fax it to the clerk's office in the appropriate division. Abilene Fax: 325-677-6334 Email: abilene_intake@txnd.uscourts.gov Lubbock Fax: 806-472-1960 Email: lubbock_intake@txnd.uscourts.gov Amarillo Fax: 806-468-3862 Email: amarillo_intake@txnd.uscourts.gov San Angelo Fax: 325-658-6826 Email: sanangelo_intake@txnd.uscourts.gov Dallas Fax: 214-753-2266 Email: dallas_intake@txnd.uscourts.gov Wichita Falls Fax: 940-767-2526 Email: wichitafalls_intake@txnd.uscourts.gov Fort Worth Fax: 817-850-6633 Email: fortworth_intake@txnd.uscourts.gov American LegalNet, Inc. www.FormsWorkFlow.com