EFTA01078076.pdf

GOVERNMENT OF THE UNTIED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BUSINESS AND FINANCIAL MANAGEMENT 1105 King Slreel • ChMHonied. Vin Islands00820 • 340.773.6449 • 18 Raiment Gale • ChoRolle Amore. Viloin Woods 00802 • 340.774.2791 • CREDIT CARD AUTHORIZATION FORM PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN IT TO OUR OFFICE BY FAX: (340) 776-5039 OR BY REGULAR MAIL. (Please provide a copy of your personal identification e.g. driver's license or passport) Date: March 20.2015 Cardholder Name: Contact Number : - - Email: Signature: Billing Address: Credit Card Type: ❑ VISA ❑ MASTERCARD ❑ ATM/ATH CARD Credit Card Number: Expiration Date: / Card Identification Number (last 3 digits located on the back of the credit card): Amount Charged: 22 303.07 (USD) Apply Amount to: 2014 Property Taxes - Parcel EFTA01078076