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 301 East 66th Street Apt 1OF New York NY 10065 Telephone: mind by wend cord. *Mos Me amount sou ors psyes In Spe mew Ws and fi WI below. Mostertard Visa Sewn Cade Elm DIM Scrotum SSI COOS Date Account 4/4/2012 9648 Remittance IMPORTANT PLEASE DETACH UPPER PORTION MD RETURN WITH YOUR REMITTANCE TO /NSURE CREDIT 70 PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/1/2012 4/3/2012 4/3/2012 4/3/2012 Previous Balance 40.00 180.00 65.00 0.00 40.00 220.00 285.00 If payment has been sent, please disregard this We accept credit cards! You may complete and this statement, or call the office at Account Total 285.00 statement - Thank You. return the top part of Current 30 Days 60 Days 90 Days 120+ Days 285.00 0.00 0.00 t 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 EFTA01118658