Clerk, US District Court District of Massachusetts 1 Courthouse Way, Suite 2300 Boston, MA 02210 (617) 748-9143 (cashier) (617) 748-9096 (fax) Attention: Cashier Request for Credit Card Payment via Telephone/Mail
Visa
MasterCard
Discover
Expiration Date
Credit Card Number
American Express
Expiration Date
Credit Card Number Four Digit ID# for American Express
Purchase Amount
Name as it appears on Card: Billing Address: Do Not Use a PO Box
$
(Exact Amount or Not to Exceed)
City Contact Name: Telephone Number: Authorized Signature: Printed Name of Signer:
State
Zip Code
Reason for Payment: