Credit Card Payment Information (Must Be Submitted With Each Payment Obligation) printable pdf download

Credit Card Payment Information (Must Be Submitted With Each Payment Obligation)

UNITED STATES DISTRICT COURT

DISTRICT OF NEW HAMPSHIRE

CREDIT CARD PAYMENT INFORMATION

(MUST BE SUBMITTED WITH EACH PAYMENT OBLIGATION)

YOUR OBLIGATION TO THE UNITED STATES DISTRICT COURT

MAY BE SETTLED WITH YOUR VISA, MASTERCARD,

DISCOVER,OR AMERICAN EXPRESS

INSTRUCTIONS:

Accounting Use Only

1. Completely fill out all blanks to ensure proper processing of

this credit card form.

2. Mail completed form to:

Clerk, US District Court

55 Pleasant Street, Room 110

Concord, NH 03301-3941

Authorization number

Authorization date

Reference number

Q Q Q Q Visa

Q Q Q Q MasterCard

Q Q Q Q Discover

Q Q Q Q American Express

My Bank Card Number is:

Good thru:

CVC2 Number: (This is the 3 or 4 digit code on the back of the credit card.)

Payment Amount:

Case Number:

State reason for payment:

(Print)

Name _________________________________________________________________________________________

Address _______________________________________________________________________________________

City _______________________________________ State ________________ Zip _________________________

Daytime Phone No. ____________________________________

Cardholder acknowledges that the United States District Court will apply the payment amount shown above to the debt(s)

represented by the referenced docket number. Cardholder agrees to perform the obligations set forth in the cardholder’s

agreement with issuer.

_______________________________________________________________

Authorized Signature

Date

USDCNH-65 (Rev. 4/09)

Credit Card Payment Information (Must Be Submitted With Each Payment Obligation)