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