United States Bankruptcy Court
Eastern District of Oklahoma
Credit/Debit Card Authorization Form
Name of Attorney/Participant:
I hereby authorize the United States Bankruptcy Court for the Eastern District of Oklahoma to charge the following
credit/debit card for payment of fees and other court related matters.
Type of Card
Credit Card Number and Expiration Date
V code on back of the card in italics
CID Code by expiration date 4-digits
Visa Debit Card
Diner’s Club Card
MasterCard Debit Card
Nam e on Card
Phone Num ber:
Please indicate if this information is: New ‘ Updated ‘
This form will be kept on file in the Clerk’s Office and shall remain in effect until specifically revoked in writing. It is the
responsibility of the cardholder named herein to notify the Clerk’s Office of the new expiration date when a credit card has
been renewed, canceled or revoked. This information will be securely maintained in the Clerk’s Office.
In the event the charge against this account is denied, you will be notified immediately to make payment in cash, money order
or certified check. Any abuse of this privilege may result in your removal from the credit card program.
Please return completed form to: U.S. Bankruptcy Court, Financial Dept., P.O. Box 1347, Okmulgee, OK 74447