Print Form Clear Form UNITED STATES DISTRICT COURT WESTERN DISTRICT OF WASHINGTON CREDIT CARD COLLECTION NETWORK AUTHORIZATION FORM We/I hereby authorize the United States District Court Western District of Washington to charge the following bank card number(s) for payment of filing fees and other court related expenses. Name as it appears on Card:_______________________________________________________ Name of Law Firm: Name of other authorized users:_______________________________________________ _________________________________________________ _________________________________________________ Cardholder’s mailing address:_________________________________________________ City:______________________________State:__________ Zip Code _________________ Business Mailing Address:____________________________________________________ ___________________________________________________________________________ Business Phone No:_______________________Fax No:____________________________ Master Card No:________________________________________ Exp. Date_________________ Visa Card No:__________________________________________ Exp. Date_________________ Discover Card No:______________________________________ Exp. Date_________________ American Express:_____________________________________ Exp. Date_________________ (AE ID #) :______________________ Diners Club:__________________________________________ Exp. Date_________________ Please indicate if this information is: NEW [ ] UPDATED [ ] This form will be kept on file in the clerk’s office, and shall remain in effect until specifically revoked in writing. It is the responsibility of the firm/company named herein to notify the Clerk’s office of the new expiration date when a credit card has been renewed, or if a card has been canceled or revoked. Signature:____________________________________________Date:______________________ *In the event the charge against this account is denied, you will be notified immediately to make payment in cash, money order or certified check. Any abuse of this privilege may result in your removal from the credit card program. **PLEASE RETURN COMPLETED FORM TO THE FINANCIAL DEPARTMENT, U.S. DISTRICT COURT WESTERN DISTRICT OF WASHINGTON, 700 STEWART STREET, LOBBY LEVEL, SEATTLE, WA 98101. American LegalNet, Inc. www.USCourtForms.com