Receipt

Order ID: INT131231-4665-16644
Order Created: December 31, 2013
Paid In Full: December 31, 2014

Purchaser

Deb Patterson
Contact Care Line
P. O. Box 4641
Oak Ridge, TN 37831
United States

Product Support
https://www.jotform.com
support@jotform.com

Seller

FastSpring
801 Garden Street
Suite 201
Santa Barbara, CA 93101

questionacharge.com
W-9 Form

Description Quantity Sales Tax Amount
JotForm Premium Yearly
Billed yearly. Next Billing Date On 12/30/14
1 $0.00 $90.00
Discount - $45.00
Subtotal $45.00
Sales Tax (0%) $0.00
Total $45.00