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 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 1-09803-0101-00 EFTA00589299