Credit Card Authorization Form Type of Card Visa [) MasterCard® American Express Expriration Date 06/21 Security Code 9049 7m Name onthe Card Jeffrey Epstein Company Name Billing Address 9 East 71st Street New York, NY 10021 Phone Number | emat By signing this form, you authorize TAKARA BELMONT USA, Inc to charge your card for the amount of listed SALES ORDER By security reason, we will discard this form after charged your amount for this order. Therefore, TAKARA BELMONT USA, Inc will never possess your credit card's information EFTA00313950