Store Credit Withdrawal Test

Not for external use

N/A

Contributor

First Name

Last Name

Street Address

City

State

ZIP

Country

Phone

Legal Compliance

I certify under penalty of perjury under the laws of the City of Los Angeles and the state of California that all of the following statements are true and correct.

I have read and accept the Democracy Engine Terms of Service and Privacy Policy.
I am at least eighteen years old.
I understand that my payment is being made to Democracy Engine, who accepts the responsibility of distributing the funds to my designated recipient(s). My card or bank statement will show a payment to “Democracy Engine” and if there are any issues or discrepancies with the payment or I wish to revoke the payment, I can contact Democracy Engine at support@democracyengine.com.

Recipients & Amounts

Jonathan Zucker
$
TOTAL
$

Payment method

Credit Card Electronic Check Store

Credit Card

Card Number Four_cards

Expiration Date

Security Code (CCV)

Electronic Check

Account Type

Checking Savings

Routing (Bank) Number(omit any dashes or spaces)

Retype Routing Number

Account Number(omit any dashes or spaces)

Retype Account Number

Store Credit Account Withdrawal

Store Credit Account Withdrawal Token