15 Sally CodeRN i I k0Rafitarl WassDEE E MEIE-01100 I Esp. Date: f_ &of* Coat 11111 1 aN as k appears on the card: i :DARREN K. INDYKE I I Bang Addivec 1,575 LEXINGTON AVENUE, 4Th FL Cte [WV' YORK CrEC CCEC INY 2/04:00a 10022 Total Fees from Applicable Fees Page FEE a Travelers TOTAL US Gov