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 SHINE, BASIE D
Drivers License
State
Drivers License #
Date Of Birth 04261973
Case Number TR04-0002009
TicketNumber M7429638
Issue Date 07172004
Court Date 08192004
Offense Description 32-7A-16; FAILURE TO DISPLAY INSURANCE
Total Fine 198.00
Date Paid
Auth Num