NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION Page 1 of X
Please detach and return lower portion with your payment to ensure proper credit. Retain upper portion for your records.
**N000006
004
Mail
Checks
To
Approval Section
Memo Section
_______________________________________________________ __________________________________________________________
CARDHOLDER SIGNATURE APPROVING OFFICIAL SIGNATURE (Except Travel)
XXXX-XXXX-XXXX-1234
Month DD, CCYY
$9,999,999,999,999.99
$999,999,999.99
$9,999,999,999,999.99
Agency/Org ID: 9999997 Single Purchase Limit: $99,999,999,999,999 Credit Limit: $99,999,999,999,999
Billing Office ID: 9999999990 Discretionary Code: 999999999099999999929999999993 Tax Exempt #: 99999999909999999992999996
Accounting Code: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Citibank
ADDRESS LINE 1
CITY ST ZIP+4
JOHN Q CARDHOLDER
COMPANY NAME
ADDRESS LINE 1
ADDRESS LINE 2
ADDRESS LINE 3
CITY ST ZIP+4
COUNTRY NAME
Account Inquiries:
Toll Free:
Intl.
TDD/TTY:
1 (800) 790-7206
1 (904) 954-7850
1 (877) 505-7276
Account Statement
Government Card Account
(Account Name)
Govt IBA Cardholder Statement
Account Number: XXXX-XXXX-XXXX-XXXX
Payment Information
New Balance
$9,999,999,999,999.99
Past Due Amount
$0.00
Amount Over Credit Limit
$99,999.99
Minimum Payment Due
$9,999,999.99
Payment Due Date MM/DD/CCYY
Statement Closing Date MM/DD/CCYY
Days In Billing Period
XX
Summary of Account Activity
Previous Balance
$9,999,999,999,999.99
Payments
$9,999,999,999,999.99
Credits
$9,999,999,999,999.99
Purchases & Cash Advances
$9,999,999,999,999.99
Interest Charges
$9,999,999.99
Statement Messages supplied by Statement Designer (Message Area 1)
Note: This space should shrink/expand based on messages to be printed from Campaign Manager. If no messages are to
be printed from Campaign Manager then this box should be removed and the section containing messages from the TSYS
file should be printed in this location.
(flow)
Send Notice of Billing Errors and Customer Service inquiries to:
Citibank, P.O. Box 6125, Sioux Falls SD 57117
Transactions
19/99 19/99 9999 99999999919999999992993 999999 XXXXXXXXX0XXXXXXXXX2XXXXXXXXX3XXXXXXXXX41 31909 USA 999,999,999.99 CR
19/99 19/99 9999 99999999919999999992993 999999 XXXXXXXXX0XXXXXXXXX2XXXXXXXXX3XXXXXXXXX41 31909 USA 999,999,999.99 CR
19/99 19/99 9999 99999999919999999992993 999999 XXXXXXXXX0XXXXXXXXX2XXXXXXXXX3XXXXXXXXX41 31909 USA 999,999,999.99 CR
19/99 19/99 9999 99999999919999999992993 999999 XXXXXXXXX0XXXXXXXXX2XXXXXXXXX3XXXXXXXXX41 31909 USA 999,999,999.99 CR
19/99 19/99 9999 99999999919999999992993 999999 XXXXXXXXX0XXXXXXXXX2XXXXXXXXX3XXXXXXXXX41 31909 USA 999,999,999.99 CR
Post Trans
Date Date MCC Reference Number Description/Location Amount
28000 9999999 9999999 9999999 7461142211111111 2501
RETURN NAME
ADDRESS LINE 1
CITY ST ZIP+4
Account Number
Payment Due Date
New Balance
Past Due Amount*
Minimum Payment Due
Amount Enclosed
*Past Due Amount is included in the Minimum Payment Due.
amount.