📄 Extracted Text (137 words)
GOVERNMENT OF
THE UNEED STATES VIRGIN ISLANDS
OFFICE OF THE LIEUTENANT GOVERNOR
DIVISION OF BUSINESS AND FINANCIAL MANAGEMENT
I 105 King Dreel • Chrislionslect nip Islands 00820 • 340.7716449 •
ILL Kon0ens Gods • Chmlolle Amok.. %Amin WOMIS 00802 • 340174.2291 •
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 personalidentification e.g. driver's license orpassport)
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 1-09803-0101-00
EFTA00589299
ℹ️ Document Details
SHA-256
ea2bb150921e35d4aa2846f8b57f33a1d9c240c1c17ea6c4f3e86753e5aa8135
Bates Number
EFTA00589299
Dataset
DataSet-9
Document Type
document
Pages
1
Comments 0