chrome/browser/resources/options/autofill_edit_creditcard_overlay.html

<div id="autofill-edit-credit-card-overlay" class="page" hidden>
  <div class="close-button"></div>
  <h1 id="autofill-credit-card-title"></h1>
  <div class="content-area">
    <label class="settings-row">
      <div i18n-content="nameOnCardLabel"></div>
      <input id="name-on-card" type="text">
    </label>

    <label class="settings-row">
      <div i18n-content="creditCardNumberLabel"></div>
      <input id="credit-card-number" type="text">
    </label>

    <div class="settings-row">
      <div id="creditCardExpirationLabel"
          i18n-content="creditCardExpirationDateLabel"></div>
      <select id="expiration-month" aria-labelledby="creditCardExpirationLabel">
      </select>
      <select id="expiration-year" aria-labelledby="creditCardExpirationLabel">
      </select>
    </div>
  </div>

  <div class="action-area button-strip">
    <button id="autofill-edit-credit-card-cancel-button" type="reset"
        i18n-content="cancel"></button>
    <button id="autofill-edit-credit-card-apply-button" type="submit"
        class="default-button" i18n-content="ok" disabled></button>
  </div>
</div>