Credit Card Blanket Authorization Form. This is a West Virginia form and can be use in District Court Federal.
Tags: Credit Card Blanket Authorization, B, West Virginia Federal, District Court
FORM B (Not necessary unless incurring costs in filing.) UNITED STATES DISTRICT COU RT SOU TH ERN DIST RICT OF W EST VIRG INIA CREDIT CARD BLANKET AUT HORIZATION FORM (FOR ATTORNEY USE - PRINT OR TYPE ONLY) I hereby authorize the United States District Court for the Southern District of West Virginia to charge the credit card(s) identified below for payment of fees, costs and expenses that are incurred by me or by the authorized users that I have listed below. I understand that I do not need this form if I do not intend to incur such costs. This form must be signed by the person whose signature appears on the back of the credit card. Individual or Firm Name (print) ____________________________________________________________ Address on card: Street or POB _____________________________________________________________ City, State, Zip: _____________________________________________________________ Telephone Number: _____________________________ Facsimile Number: ___________________________ Credit Card Holder Name: _____________________________________________________________ Names of persons within your firm who are authorized to use the credit card(s)/account number(s) that you have provided: __________________________________________ _______________________________________ __________________________________________ _______________________________________ American Express Account No.: ____________________________________ Exp. Date: _______________ Visa Account No.: _______________________________________________ Exp. Date: _______________ MasterCard Account No.: _________________________________________ Exp. Date: _______________ Discover Account No.: ___________________________________________ Exp. Date: _______________ Name of person who you wish to receive receipts for payment: _________________________________________ In the event the charge against this account is denied, we will notify you 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. _________________________________________________ AUTHORIZED SIGNATURE ____________________________________ DATE This form will remain on file in a secure location with this office and will remain in effect until specifically revoked in writing by the person with authority to cause such revocation and/or the expiration date of the card has passed. It is the responsibility of the law firm named above to complete a new credit card blanket authorization when a credit card has been renewed, revoked, canceled or stolen and when a person or persons are added or deleted from this authorization. Completion of this form is not necessary for purposes of filing in CM/ECF unless and until the filing attorney intends to incur fees, costs, or expenses. Please return completed form to: United States District C ourt, Southern D istrict of W est Virginia Attn: CM/ECF Registration 300 Virginia Street East, Room 2400 Charleston, WV 25301 American LegalNet, Inc. www.USCourtForms.com