STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: It writ by code cent enter the imam you ere meet n the MEPROPPO bat end ■ cul Italcev. Mailatettl Ube Amex Cads Eap Oleo SIgsuhre baa Cale Date Account 10/29/2015 Remittance IMPORTANT • PLEASE DETACH UPPER POW ION AND RETURN Writ YOUR REACTANCE TO MG ler CRECXT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 9/30/2015 9/30/2015 9/30/2015 10/20/2015 Jeff Jeff Jeff 3,000.00 525.00 220.00 220.00 3.220.00 3,745.00 3,525.00 Account Total 3,525.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete op part of this statement, or call the office a Current 30 Days 60 Days 90 Days 120+ Days 3,525.00 0.00 0.00 0.00 0.00 Thomas .1. Magnani D.D.S. Alvin Grayson O.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA00311439