| 10/19/2011 |
| 09:23:45 |
| Name | Member No. | Cycle | Amount | CC No. | Authorization | Auth. Date |
| FORSMAN, CRYSTA, | 6D-005299 | R | 64.00 | 4494********4089 | 956051 | 10/19/11 |
| Count | Card Type | Total |
| 0 | American Express | 0.00 |
| 0 | MasterCard | 0.00 |
| 1 | Visa | 64.00 |
| 0 | Discover | 0.00 |
| 0 | Other | 0.00 |
| 64.00 |