Fill and Sign the Card Authorization Form File

United States District Court Southern District of Iowa Credit Card Authorization Form INSTRUCTIONS: Please type or print. Mail completed and signed form to: U.S. District Court, P. O. Box 9344, Des Moines, IA 50306-9344. Firm / Company: ________________________________________ Phone number: ___________________________ Credit Card Type: VISA MasterCard Discover American Express Card Holder Name: _________________________________________ Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date: __ __ / __ __ (MM/YY) Credit Card Statement __________________________________________ Mailing Address: (Street address or P.O. Box) (Please be sure to list the address that the credit ____________________, __ __ Zip: __ __ __ __ __ card company is sending (City, State & Zip) your statements to.) I acknowledge that the above information is accurate and that I am an authorized signer of the account. I hereby authorize the United States District Court for the Southern District of Iowa to charge the above credit card account court fling fees incurred by our frm or company. Date: _______________________________ Signature ________________________________ Print Name This form, which will be kept on fle in the Clerk = s Ofce, shall remain in effect until specifcally revoked in writing. It is the responsibility of the attorney/frm named above to notify the Clerk = s Ofce of the new expiration date when a credit card has been renewed, or if a card has been canceled or revoked.