STATEMENT

STATEMENT Thomas J. Maiip Alvin Grayson Mr. Jeff Epstein 9 East 71st Street New Yoek NY 10021 Telephone: rm." by midi ma *Mar no strcom yod teprip ale ImEMMIEE km ES SE am Won. Mtilermrd Visa Ara CAM P Erb Ode 9VICETI Sc Co* Date Account 9/30/2015 8150 Remittance IMPORTANT • FUME OETACH UPPER PORTION NC RETURN WTH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 8/26/2015 0.00 9/3/2015 40.00 40.00 9/3/2015 180.00 220.00 9/3/2015 75.00 295.00 9/17/2015 1,900.00 1195.00 Account Total 2,195.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete and return the top part of this statement, or call the office a Current 30 Days 60 Days 90 Days 120• Days 2,195.00 0.00 0.00 0.00 0.00 Thomas J. MagnentlE. Mein Goyim= EFTA01122951