Santa Cruz — SUPAD 982

Source: https://www.santacruz.courts.ca.gov/system/files/forms-and-filings/supad-982-credit-card-authorization-form.pdf

SUPAD 982

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ

SANTA CRUZ BRANCH WATSONVILLE BRANCH
701 Ocean Street 1 Second Street
Santa Cruz, CA 95060 Watsonville, CA 95076

ONE-TIME CREDIT CARD PAYMENT AUTHORIZATION

Use this form for the payment of filing fees in non-criminal cases. It will not be accepted for payment of criminal or traffic fines.

Sign and complete this form to authorize the Superior Court of Santa Cruz County to make a one-time debit to your credit card as listed below.

By signing this form, you give the Court permission to debit your account for the amount indicated on or after the indicated date plus a transaction processing fee (approx. 2.95% minimum $1.00 fee). This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I (full name) ______________________________ hereby authorize the Superior Court of Santa Cruz County to charge my credit card account indicated below for (enter dollar amount of NTE amount) _____________ plus the court’s transaction processing fee (approx. 2.95% minimum $1.00 fee) on or after (date) __________________.

This payment is for (include case number and/or reason for payment) .

Billing Address:

City, State, Zip

Phone# Email:

Credit Card Type: Visa MasterCard Discover

Cardholder Name

Credit Card Number

Expiration Date _________

CVV Number ________

I hereby authorize the Superior Court of Santa Cruz County to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the case and/or a service described above and only for the amount indicated above and is valid for one-time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

SIGNATURE DATE

☐Authorization received over the telephone by , deputy clerk

Form Adopted for MANDATORY USE ONE-TIME CREDIT CARD AUTHORIZATION Page 1 of 1 Superior Court of Santa Cruz County SUPAD 982 08/04/26