STATEMENT

STATEMENT Thomas J. Ma Alvin Gra son Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephon a AEON by asS GAM fl it iha mewl SY Si tette b M riltanCeeo»PIR a as beRm IluPwanS MAE Ins OSA Re Oslo Scant 6a Cede Date Ao:ount 4/30/2015 10949 Remittance WPORTART MEW DETACH UPPER PORTION MD RETURN WM YOUR REMTITMCE TO INSURE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 4/6/2015 4/6/2015 4/6/2015 Previous Balance 60.00 180.00 200.00 0.00 60.00 240.00 440.00 Account Total 440.00 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 Current 30 Days 60 Days 90 Days 120+ Days 440.00 0.00 0.00 0.00 0.00 Thomas A Magnani M . Alvin Gmyson EFTA01122969 STATEMENT Thomas J. Maanaai Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephon a payee by ANN NAL at I,. ran MI MO 11010 SI to ilia box awl El NA Odom lissisocard Amu Cads &posts Span Sc CTN. Dale Account 6/3/2015 10949 Remittance **OMNI • PLEASE DETACH UPPER PORTONNORETURN WTH YOUR RDATTANCE TO INELRE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 4/30/2015 Previous Balance 440.00 5/11/2015 425.00 865.00 5/11/2015 375.00 1,240.00 5/11/2015 325.00 1,565.00 5/13/2015 2,200.00 3,765.00 5/21/2015 440.00 3,325.00 'N I CI ‘( 1°q (41, Account Total 3,325.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete rt of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 3,325.00 0.00 0.00 0.00 0.00 Thomas J. Macneill M. Alvin Grayson M. Floor New York NY 100t9 EFTA01122970