INSTRUCTIONS FOR COMPLETING FORM: This form must be typed. The signature field must be signed by the person whose signature appears on the back of the credit card. You must photocopy your credit card (BOTH SIDES) and attach the copy to this form. United States Bankruptcy Court Eastern District of Virginia CREDIT CARD ONE TIME AUTHORIZATION FORM I hereby authorize the U. S. Bankruptcy Court for the Eastern District of Virginia to charge the credit card listed below for payment of fees, costs, and expenses which are listed bel I certify that I amow. authorized to use this credit card . Credit Cardholder Name: _____________________________________________________ Signature: ______________________________________ Date: ________________ Company/Firm Name: _____________________________________________________ ___ Address: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Telephone Number: ________________________________ CARD TYPE: (Check card type below) MasterCard VISA Discover American Express ** Diners Club ** American Express ID Number:______ (This four digit number is printed on your card above the embossed account number.) Account Number:___________________________________ Exp. Date: ____________ CHARGE INFORMATION: Please list the appropriate amounts for each applicable charge. Filing Fee (for new cases) $______________ Motion Fee $______________ Conversion Fee $______________ Search Fee $______________ Copies made by court - number of copies: $______________ Certification Fee $______________ Appeal Fee $______________ File Retrieval from Archives $______________ Complaint Fee $______________ Other:_______________________________________ $______________ TOTAL CHARGES $______________ Court use only: Receipt # _________________ Date ____________________ [Revised 12/04/03]