Credit Card Payment Form printable pdf download

Credit Card Payment Form

You must ensure the amount stated below is consistent with the fee payable on

your completed application/request. If you are uncertain of the correct fee

please contact the courts on 1300 352 000.

The form must accompany any mailed applications or requests that require

payment (unless payment is made via cheque or money order). Please do not fax this form

unless directly requested to do so by the courts.

Attach this form to your application/request.

MASTERCARD

VISA

–

CARD NUMBER:

EXPIRY DATE:

CARD HOLDER'S NAME (as appears on the card):

CARD HOLDER’S ADDRESS:

CITY:

POSTCODE:

COUNTRY:

PHONE NUMBER: ( )

EMAIL:

TOTAL AMOUNT: AUD$

I authorise the Family Court and Federal Circuit Court to debit my credit card with the amount shown

above

. I certify that I am over 18 years of age.

CARD HOLDER’S SIGNATURE _____________________________

DATE

Due to privacy issues the courts will not issue credit card transaction receipts. Instead, the

Family Court and Federal Circuit Court receipt should be taken as evidence of the credit card

being debited.

Please note that when you email the courts the content of your message, as it is

transferred across the Internet, may not be secure. If you have concerns about the

security of your message, please contact the courts directly by phone, fax, or post.

OFFICE USE ONLY

REGISTRATION CODE

APPLICATION/REQUEST REFERENCE

RECEIPT NO

DATE PROCESSED

Authorised by Executive Director Client Services

0313 V1

Credit Card Payment Form