United States Bankruptcy Court - One Time Credit Card Authorization Form
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1United States Bankruptcy Court – Eastern & Western Districts of Arkansas
ONE TIME CREDIT CARD AUTHORIZATION FORM
INSTRUCTIONS FOR COMPLETING FORM:
This form must be typed and can be completed electronically on our website,
Press the tab key to advance to each field. A handwritten signature is required. This form must be faxed to 501-918-5520.
Based on the Administrative Office of the US Courts’ policy, copies from cases filed prior to December 1, 2003, will be
provided via regular mail.
I hereby authorize the U.S. Bankruptcy Court to charge the credit card listed below for payment of fees, costs and expenses
which are listed below. I certify that I am a person who is authorized to use this credit card.
Credit Cardholder Name:______________________________________________________________________________________
Street, City, State, Zip:________________________________________________________________________________________
Telephone Number:_____________ Fax Number:______________ Email address(optional)________________________________
Signature:_____________________________________________________
Date:______________________________
Card Information:
Account Number:_______________________________________________
Expiration Date:____________________________
Card Type:____________________________________
Charge Information:
Quantity
Fee Amount
Total Fees
0.00
Filing Fee
_______
___________
__________
0.00
Installment Fee
_______
___________
__________
0.00
Motion for Relief, Motion for Abandonment
_______
$181.00
__________
Motion to Sell Property Free & Clear of Liens
0.00
Under 11 U.S.C. §363(f)
_______
$181.00
__________
0.00
Conversion Fee
_______
___________
__________
0.00
Search Fee
_______
$ 31.00
__________
0.00
Copies
_______
$
.50
__________
0.00
Certification
_______
$ 11.00
__________
0.00
Appeal Fee
_______
___________
__________
0.00
Archived File Retrieval (one box)
_______
$ 64.00
__________
0.00
Archived File Retrieval (each add’l box)
_______
$ 39.00
__________
0.00
Adversary Fee
_______
$350.00
__________
0.00
Other _____________________________
_______
___________
__________
0.00
Total to be Charged
________
Please list all debtor(s) and case number(s):
1. __________________________________________________________________________
2. __________________________________________________________________________
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