Receipt

Order ID: INT200210-9243-35581
Order Created: February 10, 2020
Paid In Full: February 10, 2020

Purchaser

Amy DeFilippo
HealthSource Chiropractic
36901 American Way
Ste 7
Avon, OH 44011
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 Storage Monthly
Billed monthly. Next Billing Date On 3/9/20
1 $0.36 $5.00
Subtotal $5.00
Sales Tax (7.2%) $0.36
Total $5.36