Receipt

Order ID: INT141120-1935-50891
Order Created: November 20, 2014
Paid In Full: November 20, 2014

Purchaser

Nichole Faina
Family Services of Western PA
6401 Penn Ave 2nd floor
Pittsburgh, PA 15206
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 Monthly
Billed monthly. Next Billing Date On 12/19/14
1 $0.00 $9.95
Subtotal $9.95
Sales Tax (0%) $0.00
Total $9.95