SCOTT COUNTY ATTORNEY’S OFFICE
DELINQUENT FINE COLLECTION
Scott County Courthouse
400 West Fourth Street
Davenport, Iowa 52801-1104
Telephone: (563) 326-8235
Fax: (563) 326-8763 www.scottcountyiowa.com
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CREDIT / DEBIT CARD AUTHORIZATION FORM
I, ______________________________________________, who’s date of birth is ____________________
do hereby authorize the Scott County Attorney’s Office to charge my credit card as follows:
$ _______________ today
Hereafter, the charge (credit or debit) will be $ _______________ Weekly / Biweekly / Monthly (circle one)
On the _______________ day of each Week / Month (circle one) until paid in full.
Credit / Debit Card Number: _______________________________________________________________
Expiration Date: _________________________________________________________________________
Three Digit Code (on back of card): _________________________________________________________
Billing Address For Card: __________________________________________________________________
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Your Phone Number: __________________________________________________________________
Your Email Address: __________________________________________________________________
(The system will send you a receipt for payment.)
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Signature Authorizing Credit / Debit Payment Date
Your handwritten signature is required before processing the form
