EFTA00314142.pdf

ts Send to: G3 C;lobal Services. Attn: Passport Department 388 Market street. Sudo 1520 San Francine:0. CAA 94111 fit/8981203 I SanHancir.roco3vC.:c: cool SAN FRANCISCO SECOND VALID PASSPORT YCcr be Srt 10 sitAir ccitacl email • Check here' you require a hard copy incILIded ',tat your return teiweri Payment Information I :Payment Via Chock D Ix: I ,ayrtiont Via Credit Card: yisarpAasal card: 54 74. I S13-7308-9256 Exp. Date. 11 / 19 Security Code: 3 5 7 OR American Express: Exp. Date: / Security Code: Name as it appears on the card: Darren K. Indyke Billing Address: 575 Lexington Ave. 4th Floor bay NY Signature. State NY Zip: 10022 Ap;.,rovc;! ! • • l• G3 CuStomer Number, Billets. P.O.. Project or Reference Codes: x Ooncierqe Service Requested e :w.r! App:!cable, ! Page FEE # Travelers TOTAL Concierge Fee $175.00 X = $1 75.00 US Government Fee Si 7o.00 x $170.00 G3 Service Fee $275.00 X = $275.00 Passport Protection Pto $40.00 X = $40.00 Return Deivery Fee $5.00 Subtotal 58565.00 Add 5% for credit card conversance fee $37.20 Total Payment Enclosed $70220 Traveler Information Traveler 1 Name: Jeffrey Edward Epstein Tamar 2 Name Dated BAT 01/20/1953 Date of Birth: Passport Service Service: x Seccod Wad Passport (Rook Only) Processing Speed: x hessian Critical Primly Dmedded Second Said Passport (Book and Card) Travel Details Date of US Departure ANTICIPATED 06/_/2016 Other visa or passport sernces requested: Notes: I must have my passport no laW than: 06/ /2016 Contact Information Name: Darren K. Indyke Creed Entail (required): Daytime Phone Company: Darren K. Indyke, PLLC " i/ePha Return Delivery Address Wne: Darren K. Indyke Street Address-. 575 Loxington, 4th Floor eitf Now York Daytime Phone. Company: Darren K. Indyke, PLLC State: NY Zip Code: imp Mobile Phone: t EFTA00314142