Credit Card Payment Authorization Form
If you wish to pay by MasterCard or Visa, 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) 866-3080 for Rockford 1st Division or (616) 336-8050 for Grand Rapids 2nd Division. IF YOU ARE SUBMITTING THIS FORM BY MAIL OR BY FAX, YOU MUST ALSO INCLUDE A PHOTOCOPY OF BOTH THE FRONT & BACK OF THE CREDIT CARD. PAYMENTS SUBMITTED WITHOUT THE ORIGINAL CREDIT CARD OR A PHOTOCOPY OF BOTH SIDES OF THE CREDIT CARD WILL NOT BE PROCESSED FOR PAYMENT
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 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 # ___________________________
