Authorization to Make Charges to Credit/Debit Card

Fax back to 706-636-5293

*** YOU MUST INITIAL AT ALL FOUR (4) PLACES FOR AUTHORIZATION TO BE ACCEPTED ***

Business making this charge to Card Holder=s card: Jeffrey I. Fouts, Attorney at Law
(Hereinafter referred to as AAttorney@)

I, Card Holder, hereby freely authorize, agree and approve of the following:

1) I hereby authorize and approve Attorney to make the following one-time charge to my credit or debit
card. I understand Attorney will not make any future charges to my credit card without my written
approval.
Amount to be charged to Card Holder’s Credit card: $_____________

___________ Card Holder’s Initials Not Typed

2) I understand and agree that I am purchasing legal or accounting services, and that this fee to be charged
will be earned by Attorney and his staff at the rate specified in your client attorney agreement.

___________ Card Holder’s Initials Not Typed

3) I understood and fully agree to accept that any itemized billing statement presented for services rendered
by Attorney and his staff to Client will be sufficient evidence to show that the legal or accounting work
has been fully performed and that those fees have been rightfully earned. I fully agree that any such
itemized billing statement shall be sufficient to settle any dispute that the legal or accounting work was in
fact performed and that the legal fees have been rightfully earned.

___________ Card Holder’s Initials Not Typed

4) Card holder=s full name as appears on

card:___________________________________________________

Credit card account No.

__________________________________________________________________

Expiration
date:_________________________________________________________________________

Security code 3-digit on back, Am. Ex. has 4-digit code on

front:__________________________________

Card holder’s billing address: _____________________________________________________________

_______________________________________________________________________
_______________________________________________________________________

___________ Card Holder’s Initials Not Typed

I have read this Credit card charge agreement. I have received a copy of this document, and I have had
ample opportunity to ask any questions concerning it. I fully understand, and I fully agree, to its terms and
conditions. It is understood and agreed that this document does not contradict any Attorney-Client
Agreement also signed.

Dated: This the ____________ day of ____________________________, 2010

Signed and approved by Card Holder:

__________________________________________
Card Holder