"First Name" field is required.

"Last Name" field is required.

"Street Address" field is required.

"City" field is required.

"ZIP Code" field is required.

"State" field is required.

"Country" field is required.

"Cardholder Name" field is required.

"Card Number" field is required.

"Expiration Date" field is required.

"Security Code" field is required.

Card Or Magstripe Required

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Current balance $10.00

Minimum payment amount $5.00

Other amount $ Minimum payment amount is $5.00.

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Street Address *

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ZIP Code *

State *

Country *

Credit Card

Cardholder Name *

Card Number *

Expiration Date *

Security Code *

Billing

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Last Name *

Street Address *

City *

ZIP Code *

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Country *

Credit Card

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Card Number *

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Security Code *

Invoice 233

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From: Ohr Yitzchok Radvil
Cong. Ohr Yitzchok Radvil
174 Maple Ave.
Monsey, , NY 10952
US

To: הערמאן נחום מרדכי

Date: November 14, 2022

Invoice Number: 233

Invoice Due: November 28, 2022

Invoice Total: $10.00

Balance: $10.00

Task

Rate

Qty

Amount

פר’ נח עלה חמישי

$10

1

$10

Notes

Checks paypable to: Cong. Ohr Yitzchok Radvil
174 Maple Ave. Monsey, NY 10952

Terms

Please review your invoice and make payment at your earliest convenience.