MATA & PITTI

CREDIT CARD PAYMENT AUTHORIZATION FORM

THE UNDERSIGNED: Eva Paparella

WITH PASSPORT / ID NUMBER: No AA1238425 Italy

AUTHORIZE THE LAW FIRM MATA & PITTI TO DEBIT THE AMOUNT OF US$: 668

FROM MY CREDIT CARD, ACCORDING TO THE FOLLOWING INSTRUCTIONS:

CREDIT CARD: x VISA | MASTERCARD

CARD NUMBER: 4342 5749 8826 5602

CARDHOLDER NAME: Eva Paparella

EXPIRATION DATE: 06/20

CARDHOLDER ADDRESS: 5380 E Flamingo Rd No 26, Las Vegas NV 89122

SERVICE REQUESTED: renewal Foundation Global Wellbeing V. Foundation

TRANSACTION AMOUNT IN US DOLLARS: US$ 668

SIGNATURE OF CARDHOLDER:

DATE: 05/10/2016

+ KINDLY ATTACH COPY OF YOUR PASSPORT OR ID +

PLEASE SEND THIS FORM BY FAX (507) 264-6127, OR SCANNED BY EMAIL: MP@MATAPITTI.COM

MATA & PITTI

ATTORNEYS AT LAW, REPUBLIC OF PANAMA
TEL. +507-264-5570 / +507-264-5931 / FAX. +507-264-6127
PANAMA BANKING DISTRICT, ADVANCED TOWER
MP@MATAPITTI.COM
WWW.MATAPITTI.COM