Receipt

Order ID: INT170110-4215-84160B
Order Created: January 10, 2017
Paid In Full: January 10, 2017

Purchaser

Ken McCombs III
McCombs Supply Co
PO Box 4577
Lancaster, PA 17604
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 Bi-Yearly
Billed every 2 years. Next Billing Date On 1/9/19
1 $0.00 $139.00
Subtotal $139.00
Sales Tax (0%) $0.00
Total $139.00