STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. Mr. Jeff Epstein 9 East 71st Street New York NY 10021 W mine by UI Mt ere. M r,.mt Mete pyre Es Re Men IS RS • out beam Mnleteinl Vise Arne Cale* Exp One SIgresbee Sig Cede Date Account 1/7/2015 Remittance IMPORTANT - RAMIE OE TACK UPPER PORTION AID RETURN WTTN YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 12/23/2014 12/23/2014 12/23/2014 12/23/2014 Mice 40.00 180.00 24.00 65.00 0.00 40.00 220.00 244.00 309.00 Account Total 309.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and retum the top part of this statement, or call the office at Current 30 Days I 60 Days 90 Days 120+ Days 309.00 0.00 0.00 0.00 0.00 I-nmas J. Magnani D.D.S. Alvin Grayson U.D.S. EFTA01136008 STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Gr n D Date Mr. Jeff Epstein 9 East 71st Street New York NY 10021 II tube.; by aNSI cat mitt Mt Smart you n myna in tm conaanco Ma end III mil tett Mentraird Amex Cat t Ey Das DOTIRTte St Coot Dam Account 1/7/2015 Remittance IMPORTANT. PLEASE DETACH UPPER PORTION AND RETURN wrrH YOUR FEJRTTANCE TO INSURE CREDIT TO PROPER ACCOUNT Patient 11/26/2014 12/22/2014 Description Charges Credits Balance Current 2,100.00 0.00 2,100.00 Account Total 2,100.00 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 at 30 Days 60 Days 2,100.00 I 0.00 0.00 90 Days 120+ Da 0.00 0.00 Thomas J Magnani D D.S. Alvin Grayson D 0 S. EFTA01136009