superior court of california, county of orange credit card payment form

SUPERIOR COURT OF

CALIFORNIA,

COUNTY OF

ORANGE

CREDIT CARD PAYMENT

FORM

Case

Number:

Type of Card:

VISA

MASTERCARD

DISCOVER

AMERICAN EXP

Card

Number:

Expiration

Date:

Amount:

Cardmember acknowledges receipt of goods and/or services in the amount of the total shown hereon

and agrees to perform the obligations set forth by the cardmember's agreement with the issuer.

Signature:

Telephone:( )

Print form and mail to: Information Payment Center, P.O. Box 6040, Newport

Beach, CA, 92658-6040 Or The address as listed on your citation

THIS FORM CANNOT BE USED AS A MEANS OF ELECTRONIC PAYMENT.