Fillable Credit Card Information Form printable pdf download

CREDIT CARD INFORMATION_________

Complete the information requested, print this page and mail this form and your yellow summons to:

Fairfax County General District Court, ATTN: Traffic Division, PO Box 10157, Fairfax, VA 22038.

Prepayment must be received by the court no later than the business day before your court date to waive

your presence at your court hearing.

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Visa

Master Card

Type of Card:

□

Discover

American Express

Name as Appears on Card:______________________________________________

Credit Card Number:__________________________________________________

Date of Expiration:____________________________________________________

Credit Card Verification Code:___________________________________________

To process your payment, you must provide a credit card verification code. With Visa, MasterCard or Discover there is a number printed in the

signature area on the back of the card. The verification code is the last three digits of that number. On American Express cards the verification

code is the 4-digit number found in the small print next to your account number on the front, usually above it on the right.

Total Amount Authorized:______________ Court Date:______________________

Daytime Phone Number:_______________________________________________

Printed Name of Offender, as shown on summons:__________________________

I understand that in order for this payment to be accepted, I must possess the valid credit card I have recorded

above. I have accurately recorded the correct card number and I understand that:

1. The provision of incomplete or inaccurate data by me, or my failure to sign in the space below, may result in

delays in processing. If I have made an error in calculating the amount of fines and costs, the clerk will correct

the error and charge the appropriate amount to my credit card. A 4% credit card convenience fee will also be

added to the total payment receipted.

2. If delays occur, and if I do not appear on the court date or pay the fines and costs prior to the court date,

the court will try me in my absence and, upon conviction, the judge may impose a fine that is different

from the prepayable amount established by the Supreme Court of Virginia. Also, pursuant to Virginia Code

Section 16.2-69.48:1, an additional penalty of $35.00 will be assessed for a trial in absentia.

3. Pursuant to Virginia Code Section 46.2-395, failure to pay fines and costs within 30 calendar days of the date of

conviction will result in suspension of my driving privileges in Virginia.

4. If the credit card charge is not honored, a $50.00 penalty will be charged.

Authorizing Signature:_________________________Date:____________________

(Revised January 2013)

Credit Card Information Form