UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF WASHINGTON ONE-TIME CREDIT CARD AUTHORIZATION FORM ATTORNEY USE ONLY Attach Form to the Document being filed. Submit One Form Per Document Cardholder Name: ___________________________________________________________ Credit Card #: ______________________________________________ Exp. Date: _________ Visa _____ MasterCard _____ AMEX _____ Discover _____ Diner’s Club _____ Four-Digit Number Printed on Card (American Express only) ____________ Authorized Signature _________________________________ Date: _______________ Daytime Phone #: _______________________ Case #: ___________________________ Debtor’s Name : _________________________ Document # (if already filed): ___________ Fee to be Charged: G New Petition G Installment G Motion G Complaint G Amendment G Appeal G G G G G Conversion Search Copy Certification Other ___________ Amount to be Charged: $ ___________ This form may be delivered to the appropriate Clerk's Office: United States Bankruptcy Court 700 Stewart St Room 6301 Seattle WA 98101 (206) 370-5200 United States Bankruptcy Court Union Station 1717 Pacific Ave. Tacoma WA 98402-3233 (253) 593-6310 American LegalNet, Inc. www.USCourtForms.com