Fill and Sign the Affidavit of Intent to Remit Cost Deposit Via Credit or Debit Card or Other Form of

Form No. 4A. Affidavit of intent to remit cost deposit via credit or debit card or other form of electronic payment AFFIDAVIT OF INTENT TO REMIT COST DEPOSIT VIA CREDIT CARD OR DEBIT CARD OR OTHER FORM OF ELECTRONIC PAYMENT STATE OF OKLAHOMA In the Supreme Court of Oklahoma: I, ______________________ ______________ , depose and say that I am the _____________ __ ______ , in the above -entitled case. I further state that it is my intent to remit the cost deposit for this cause of action vi a credit card, debit card or other form of electronic payment , and that I am authorized to utilize the provided method of payment . I understa nd that it is my responsibility to remit the cost deposit and to ensure that the Clerk of the Supreme Court has received and successf ully processed the cost deposit not later than two business days after the date of filing this Form 4A . I accept ful l responsibility to provide the Clerk of the Supreme Court with any and all information needed for th e processing o f my remittance. I further under stand that if I fail to timely and successfully remit the cost depos it for this cause of action in the form and manner prescribed by the Rules of the Supreme Court , my cause of action may be dismissed for failure to remit the cost deposit as required by Oklahoma law. I further understand that I should not provide , on this Form 4A, the actual credit or debi t card numbers or any other sensitive information for the processing of this cost deposit . I understand that the Clerk of the S upreme Court will not retain any of this information for any use other than the processing of this cost deposit aft er I have co mmunicated with the Clerk and provided it . I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct. __________________________ _______________ ____________________________ Date Affiant Contact Information: Name (Printed) :_________________________________________ ___________________ Address: _______ ___________________ _______________ ________________________ ____________________ _____________________________________________________ Phone Number : _____________ __________________ __________________________ __ E-mail address: __________________________ __________________________________ DO NOT PUT THE ACTUAL CREDIT OR DEBIT CARD NUMBERS ON THIS FORM, AND DO NOT SEND A PHOTOC OPY OF THE CREDIT OR DEBIT CARD