Send to: G3 Global Services Attn: Passport Department SAN FRANCISCO San a tt) SECOND VALID PASSPORT > [ ] & payable te (Payment ViaCheck :| | Saermaatie | (x) Payment Via Credit Card: Visa/MasterCard: |5! 4/7) 4).| 1] 5|| 1) 3|_|7/s\[o/a!_l9)|2)/s6 Exp. Date:_'1 /_19 Security Code: 3! 5 7 (x] Concierge Service Requeste: Total Fees from Applicable Fees Page ; , {lomo 26 appears om the card: s fe ta roe - ae Darren K. Indyke nonge Fee) $175.00X) | L pba — US Government Fee | $170.00 X | Billing Address: |S75 Lexington Ave, 4th Floor _ G3 Service Fee $275.00x| City:| NY Signature: = [] Payment Via Approved Billing Terms i G3 Customer Number, Billing, P.0., Project or Reference Code#: Total Payment Enclosed $702.20 | Add 5% for credit card convenience fee $37.20 | Traveler Information Traveler 1 Name: Jeffrey Edward Epstein Date of Birth: 94/20/1953 Traveler 2 Name: Date of Birth: Passport Service Service: _[%] Second Valid Passport (Book Only) a ie ay s (1s Valid Passport (Book and Card) Processing Speed: [>] Mission Critical [—)Priority [_] Expedited Travel Details Date of US Departure: ANTICIPATED 06/__/2016 | must have my passport no later than; 06/__/2016 Other visa or passport services requested: Contact Information Name: Darren K. Indyke Company: Darren K. Indyke, PLLC Name: Darren K. Indyke Company: Darren K. Indyke, PLLC Street Address: 575 Lexington, 4th Floor Git: New York Zi Code: 10022 EFTA00314148