10/05
UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF LOUISIANA CREDIT/DEBIT CARD ONE-TIME AUTHORIZATION FORM
I hereby authorize the United States Bankruptcy Court for the Western District of Louisiana to charge the following bank card number for payment of filing fees and other court related expenses as designated on this form. Name as it appears on Card: Signature of Cardholder: Name of Law Firm/Business: Billing Address:
(Street, P.O.Box, Other)
______________________________________
Date: _______________________
(City, State, Zip Code)
Telephone Number:
Fax Number:
CARD INFORMATION
ACCOUNT NUMBER: EXPIRATION DATE:
9 American Express
9 Visa
9 Master Card
9 Discover
9 Diners Club
CHARGE INFORMATION:
CASE NUMBER ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________
Please list the appropriate amounts for each applicable charge. FILING/SERVICE FEE AMOUNT $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________
DEBTOR NAME
_____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ ______________________
TOTAL CHARGES
$_____________