Credit Card Authorization Form
Type of Card Visa — MasterCard s American Express
Account Number
Expriration Date 06/21 Security Code 9049
Name on the Card Jeffrey Epstein
Company Name
Billing Address 9 East 71st Street
New York, NY 10021
Phone Number
E-mail
By signing this form. you authorize TAMARA BELMONT USA. Inc
to charge your card for the amount of listed SALES ORDER.
Signed J titre stein Date Nov. 23, 2018
By security son, we will discard this form after charged your amount for this order.
Therefore, TA BELMONT USA_Inc will never possess your credit card's information
EFTA00313951