THIRD PARTY CREDIT CARD AUTHORIZATION FORM

I, ____________________________________________________________________, authorize Nevada Quick Divorce
to charge $__________________to the credit card designated below for typing services and/or court costs
for ________________________________________________________ (client’s name). I understand that
Nevada Quick Divorce will process the charge immediately and that any cancellation of services at a
later date will not be entitled to a refund of services, only pre-paid court costs that have not been expended.
Once the papers have been typed Nevada Quick Divorce’s fees have been fully earned and no
refund will be given.

I waive receipt of the papers and authorize delivery of said papers to:
Name: ____________________________________________________________
E-mail Address: ____________________________________________________
Address: __________________________________________________________
City, State: ________________________________________________________
I further declare that the signature appearing below is identical with the signature on this credit card.
Name on Card ______________________________________________________
Billing Address _________________________________Zip Code _____________

By submitting this form I acknowledge that I have read, understand and agree to all disclosures and
terms as contained in this document.

_____ I Agree     _____ I Disagree (check one).

By submitting this form to Nevada Quick Divorce I am authorizing the charge to my
credit card for this purchase, the same as if I had personally signed a credit card purchase/payment
receipt and I will be responsible for all collection fees and any other fees associated with the collection
of my payment, should it become necessary.

Date of Authorization: __________________________ Telephone
Number: ____________________________

Signature of Card Holder: ___________________________

Please
fax to (775) 787-8272

COSTS: