Credit Card Payment Authorization Form
If you wish to pay by MasterCard, Visa or Discover, complete the
information below, detach and return to the Court with your
Citation.
You can not make a credit card payment over the Internet to 63rd District Court at this time. You must print this form and return it by mail, in person, or by fax at (616) 363-6211.
I would like to charge my 63rd District Court payment to
my MasterCard/Visa account.
Amount of Payment $__________
NAME OF CARD HOLDER (EXACTLY AS IT APPEARS ON CARD)
_________________________________________________________
MasterCard
Visa
Discover Expiration Date: __________
Account Number
Cardholder Signature: __________________________________________
Today's Date: _________________
** If you are submitting this payment for someone other than yourself, please indicate below the name of the person and/or case number for payment.
NAME ____________________________
CASE # ___________________________
