GRAND|HYATT GRAND HYATT TOKYO BILLING AUTHORIZATION FORM Jeffrey Epstein authorize Grand Hyatt Tokyo to charge: (print full name) (6%) CHAASIMERtC RS, i O “mm2eeR @ All Charges, O 28. +-C2nh. Re @ Rooms, Service Charge & Tax. CO SSECUnORMOLE = All car transports from Ao airports and rain bt pe listed below: ean ecarypeMmerican Express Great ar Munber578785840014006 Someone O21 wan aoe veffrey E. Epstein sanes 212 750 98957727288... cT#e Signature: cee Billing Address of credit card holder: 9 East 71st Street, New York, NY 10021 OC PMMA SFE (statement by mail not required) O MBA ( statement dy mail required) Me (LREMEBIMAOATEA Fats.) Receiver’s address(Fill in only if different from above) BET OR ey scscs ans cossnece TPES cna. cept 22-26 And. Oct.1:5 SOBA MBA MRS, SHFAORBLERT SLO THY. ENURO RM TRMTSILCO AZUSA. B AMMOMA 8 H=BELEL TIS. privacy hyatt.com [= TMM CRS! I D154 — MS — eC FS UW, SMBUS AOA, P4—LEOR ECA, ‘*All personal information is Emited to hotel-related purposes and for no other use. By submitting this form and any supporting documents, | confirm that | have read and agreed to the information | arn giving you In accordance with your Global Privacy Policy for Guests, which is available * Please attach a legible copy of the front & back of the credit card. *9LSybaA—FOIC— (ME) HRY <C KS. Grand Hyatt Tokyo 6-10-3 Roppongi, Minato-ku, Tokyo 106-0032, Japan Phone: +81 3-4333-1234 FAX: +81 3-4333-(@S54HIH#) EFTA00314144