Form H: 

BHBA Fee Disputes Program
CREDIT CARD CHARGE FORM

Return To FORMS

Download Form H in PDF Format



Petitioner’s Name:                                                                                                                                            

Respondent’s Name:                                                                                                                                       

Type of Card:           Visa____           MasterCard____           American Express____

Card Number:                                                                                                                                                  

Expiration Date:                                                             

I authorize payment of the BHBA filing fee to my charge card listed above 
in the amount of                                                                                                     $____________________


Print Name:                                                                                      


Date: _______________________ Signature:                                                                                              



IMPORTANT:


Return this form with your Request for Resolution of a Fee Dispute only if you are charging your filing fee. Also, you only need to send one copy of this charge form.

If you are paying the filing fee with a check, you do not need to complete or return this form.



Beverly Hills Bar Association
Fee Disputes Programs
300 S. Beverly Drive, Suite 201
Beverly Hills, CA 90212
310.553.6644



BHBA FORM H REVISED APRIL 2002