GRAND HYATT GRAND HYATT TOKYO BILLING AUTHORIZATION FORM lJeffrey Epstein authorize Grand Hyatt Tokyo to charge: (print full name) (Est) 0frlillPtiNr-Efleftl-PCF₹1‘. ( K .failflitelln • All Charges O n. 1 .—EXP. &t O Rooms, Service Chair aa K NSIlfrflOtriCORAN0118. El Others (please specify; All car Partworts from no room arc :an 21110../.. To the credit card listed below: t—" 41 American Express Credit Card Type: Credit Card Number:37676584M 4009 ficmina 6/21 Expiration Date: gstr Jeffrey E. Epstein Name on Credit Card: 8tFgn 212 750 98957-n*mt ortgg Phone Number: Fax Number:— 350 ---- C .111€ Signature: X Billing Address 9 East 71st Street, New York, NY 10021 of credit card holder: K Mlitati NE** (Statement by mail not required) O 14.1111atitil (Statement by mail required) Atilt adattThel5Ift0DOCIZAT(y.) Receiver's address(Fill in only if different from above) Na • m e Guest Name. * 2•=530566 and 26530862 Confirmations: from (Anvil Date/ ,Sept 22-26 Aacipeclgl i -5 r O e): CrfgAl‘tctrlotcliAtIllfil*, ark-PASCONAII,Iftt6trntttl. ttt I:100 AtUIO*J @831_AALXLt12, pracykiattoom I7211, Ittir5 rl O 01-7,4 INLET N. felsofctilY6ZON. 7t rrali personal's-Sonny-Jon is ',mired to hotel related purposes and for re Odle,' use. By submitting fhb form and any FRPRorliri documents. I confirm that I nave read and aced to the 1. • a information lam wins you k, accordance with your Global Privacy Policy for Guns, watch is evadable a re Please attach a legible copy of the front & back of the credit card. • 0 L.', ti Ft — EC)= e — (NE) tisaLl<t::to. Grand Hyatt Tokyo 810-3 Roppongi. telinato-ba Tokyo 106-0032. Japan Phone:41 3-4333-1234 FAA +81 3-4333-(Mailin EFTA00314144