Case Number Name Amount ($) 3.5% Convenience Fee($) Total to be charged($)

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Card Holder: Card Number: Card Exp Date:
Person Name VELIZ, RUPERTO
Drivers License
State
Drivers License #
Date Of Birth 07121987
Case Number TR19-0000522
TicketNumber T5808059
Issue Date 07312019
Court Date 09262019
Offense Description 32-5B-4; SEATBELT VIOLATION
Total Fine 41.00
Date Paid
Auth Num