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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS
OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF REAL PROPERTY TAX
1105 King Street • Christiansted, Virgin Islands 00820 • 340-773-6449 • 5049 Kongens Gade • Charlotte Amalie, Virgin Islands 00802 • 340-774-2991 •
SINGLE-USE CREDIT CARD AUTHORIZATION FORM
Please print, sign and return this authorization form to our office by the following methods:
By Fax to St. Thomas-St. John District:(340) 776-5039 To St. Croix District:(340) 773-0330 By
Email to any District: [email protected],
By Postal Mail: Send to one of the District mailing addresses listed above ______________________________________________________________________________
Date: _____________________
Cardholder Name: ___________________________________________________
Credit Card Type: VISA MASTERCARD ATM/ATH CARD
Credit Card Number: ________________________________________________________
Expiration Date: ____________________
Card ID Number (3 digits located on the back of the credit card): ___________
Billing Address: _____________________________________________________ _____________________________________________________ _____________________________________________________
Contact Number : ______________________ Email: ________________________
Amount Charged: (USD)$________________
Apply to Parcel #: ____-____ ____ ____ ____ ____-____ ____ ____ ____-____ ____ ________________________________________________
Signature: ______________________________________________________
Apply to Other:
