Fillable Fee payment Credit/Debit Card (Ministry of Justice New Zealand)

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Fee payment Credit/Debit Card (Ministry of Justice New Zealand)

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FP-1
October 2018
Fee payment – Credit/Debit Card
This form is used to pay the filing fee for jurisdictions administered by the Tribunals unit. It must be
filed with the form used to bring the proceeding (eg, the application, Notice of Appeal, Notice of Claim,
etc).
PLEASE FILL IN THE SECTIONS BELOW:
Part 1: Applicant details
What is your name, or your company’s name (depending on who is bringing the proceeding)?
Surname(s) _____________________________________________________
First name(s) _____________________________________________________
Or company name _____________________________________________________
What is the name of the Tribunal or Authority you’re filing with?
_______________________________________________________________________
Part 2: Cardholder details (cardholder to complete)
How much is the fee? (insert amount) $_____________________________________________
Please charge the amount specified above to my card.
If you’re not sure of the fee, see the form you’re filing with this one; it’s on that form.
Card type:
Visa
Mastercard
What is the cardholder’s name (eg, Joe Bloggs)? ____________________________________
What is the 16-digit card number? _________________________________________________
What is the expiry date on the card (mm/yy)? __/__
Please note, we will never ask for your CVC number. Do not provide this on the form.
The cardholder must sign below:
Signature: ______________________________________ Date: __________________________
We will only hold your card information while we process the payment of your fee. Once the payment
has been made, this information will be destroyed and will not be used for any other purpose. Please
note, we will never ask for your CVC number. Do not provide this on the form or at any other time.
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Fee payment CreditDebit Card (Ministry of Justice New Zealand)

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Completed 13 November 2020

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