Request For Credit Card Payment
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1UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
REQUEST FOR CREDIT CARD PAYMENT
I hereby authorize the United States District Court for the District of Minnesota to charge the
following bank card number for payment of filing fees and other court related expenses as designated on this form.
Name as it appears on Card:
Signature of Cardholder:
Date:
Name of Law Firm/Business:
Credit Card Billing Address:
Contact Person Name:
Phone Number:
CARD INFORMATION
Account Number:
Exp.
Date:
[ ] Mastercard
[ ]Visa
[ ]Discover
[ ]American Express [ ] Diners
Reason for Payment
Short Case Title:
(Required)
Transaction
Documents Sent
Amount
(new case, appeal, copies, etc.)
Enclosed
In advance on
$
Will be sent on _________
by
E-mail
Mail
Courier
Enclosed
In advance on
$
Will be sent on _________
by
E-mail
Mail
Courier
Enclosed
In advance on
$
Will be sent on _________
by
E-mail
Mail
Courier
Enclosed
In advance on
$
Will be sent on _________
by
E-mail
Mail
Courier
TOTAL CHARGES
$
Fax this form to one of the Clerk’s Offices
Between the hours of 8am – 5pm CST:
Minneapolis (612) 664-5033
St. Paul (651) 848-1109
Duluth (218) 529-3505
Fergus Falls (218) 739-5325
NOTE: As of January 1, 2013, the Court will no longer accept credit card payments by facsimile
for any purpose. Credit cards may be used to pay fees through CM/ECF and pay.gov.
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