STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr Jeff Epstein P.O. Box 806 New York NY 10150 Telephone: tt Paying by crew sac& ester the antHIN PHI are paying in She widow.* box and fa c.t below Mabnacard Mil Amex Cards Elm Dala S4raux. SIG Cade Date Account 12/1W2013 10542 Remittance IMPORTANT - PI Saar DETACH UPPER PORTION AND RETURN MTH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 0.00 12/10/2013 60.00 60.00 12/10/2013 180.00 240.00 12/10/2013 50.00 290.00 12/10/2013 150.00 440.00 12/10/2013 15.00 455.00 12/10/2013 1,100.00 1,555.00 12/10/2013 24.00 1,579.00 Account Total 1,579.00 We accept credit cards. You may complete top part of this statement, or call the office a Current 30 Days 60 Days 1,579.00 0.00 0.00 90 Days 120+ Days 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA00313303