| 11/30/2011 |
| 08:38:17 |
| Name | Member No. | Cycle | Amount | CC No. | Authorization | Auth. Date |
| BALDERRAMA, GAB, | 3U-004794 | R | 5.00 | 4190********0316 | 028562 | 11/30/11 |
| Count | Card Type | Total |
| 0 | American Express | 0.00 |
| 0 | MasterCard | 0.00 |
| 1 | Visa | 5.00 |
| 0 | Discover | 0.00 |
| 0 | Other | 0.00 |
| 5.00 |