"First Name" field is required.

"Last Name" field is required.

"Street Address" field is required.

"City" field is required.

"ZIP Code" field is required.

"State" field is required.

"Country" field is required.

"Cardholder Name" field is required.

"Card Number" field is required.

"Expiration Date" field is required.

"Security Code" field is required.

Card Or Magstripe Required

Payment Amount

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Current balance $100.00

Minimum payment amount $5.00

Other amount $ Minimum payment amount is $5.00.

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Street Address *

Street Address 2

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ZIP Code *

State *

Country *

Credit Card

Cardholder Name *

Card Number *

Expiration Date *

Security Code *

Billing

First Name *

Last Name *

Street Address *

Street Address 2

City *

ZIP Code *

State *

Country *

Credit Card

Cardholder Name *

Card Number *

Expiration Date *

Security Code *

Invoice 18044

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From: Ohel Basya Ohel Basya
83 Mivlal Ln
Highland MIlls, NY 10930
US

To: בערקאוויטש יעקב

Date: April 30, 2025

Invoice Number: 18044

Invoice Due: March 19, 2025

Invoice Total: $100.00

Balance: $100.00

Task

Rate

Qty

Amount

שמיני תשפ”ה שישי

$100

1

$100

Notes

Checks paypable to: Cong Khal Milval Serpi
83 Milval Lane Highland Mills New York 10930

Terms

Please review your invoice and make payment at your earliest convenience.

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