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Credit Card Blanket Authorization Form. This is a West Virginia form and can be use in District Court Federal.
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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
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