STATEMENT

STATEMENT Thomas J. Ma Alvin Grayso New York NY 10019 Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: [Neale. by we ese entree sewn psi we Perron* ICI ST PS II au Weft Ma011:111. We Neu cede Exp Dele Swan Sag Cods Date Account 1/7/2015 9648 Remittance PAPORTANT • PLEASE DETACH UPPER PORTION NC RETURN VRIH YOVR READTTAKE TO PUPAE CREDO TOPROPERA=0a" Date Patient Description Charges Credits Balance 11/26/2014 Previous Balance 0.00 12/17/2014 350.00 350.00 12/17/2014 40.00 390.00 12/17/2014 180.00 570.00 12/17/2014 65.00 635.00 Account Total 636.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete top part of this statement, or call the office at Current 30 Days 80 Days 90 Days 120+ Days 635.00 0.00 L 0.00 0.00 0.00 Thomas I Magnanis Mal GleySon EFTA01122971 HISTORICAL STATEMENT 17J1/2014 to 3/3/2015 Thomas J. Ma . Alvin Gra son Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: Date Asxsilt 3/3/2015 9648 NoTnnolCO liTITOATATTY•fteASIT CANACN WPM venom NO RETURN MTh YOUR lo UMACC TO AMU CRONY YOOROM ACCOUNT Date 6/20/2014 12/17/2014 12/17/2014 12/17/2014 12/17/2014 1/8/2015 1/8/2015 1/30/2015 2/9/2015 Patent Description Previous Balance Acccirunt Total 7,526.00 Charges 350.00 40.00 180.00 65.00 0,00 7,500.00 25.00 Credits 635.00 Balance 0.00 350.00 390.00 570.00 635.00 635.00 8,135.00 7,500.00 7,525.00 Patient Charges 6.160.00 Patient Payments 636.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may compel le P Part of this statement, or call the office 6:11.1iiiii ° Current 30 Days 26.00 7,600.00 J 60 Days 90 Days 129.- Days 0,00 0.00 0.00 Thames J. Magnanlilli Atiiin Grayson D.O.S. EFTA01122972 STATEMENT Thomas J. Ma . Telephone Alvin Grays II awn by ay& mod. Mt OM Mont Ku we *MC SISIsmeass Sas NW ■ *A Saw. Naiad Ws Ass Cads Ey Dols Spates S Q CsOs Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Date Account 6/3/2015 9648 Remittance sIPORTN4Y • PLEASE DETACH UPPER PORTON NC RETURN MH YOUR RIEETTNICE TO INSURE CREDIT TO PROPER OCCOSINT Date Patient Description Charges Credits Balance 4/30/2015 5/29/2015 • ( 01,...tcA 1,100.00 , 0.00 1,100.00 If payment has been sent, please disregard this We accept credit cards You may complete this statement, or call the office at Account Total 1,100.00 statement - Thank You. part of Current 30 Days 60 Days 90 Days 120+ Days 1,100.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl S Alvin Grayson M . EFTA01122973 STATEMENT Thomas J. Ma • Alvin Gra son Mr. Jeff Epstein 9 East 71st Street NewYork NY 10021 TelephoneMill PION by PPM cart cm* too OfiCtell you as paying v. to ratailanoi tag arel SPA DEEP Wasisrard Na Penn GOV Earn CME• SQ COS Date Account 10/29/2015 9648 Renter's IMPORTANT • PLEASE MACH UPPER PORTKIN NC RETURN NTH YOUR PRUARTANCI TO MUNE CREDIT TO PROPER Accouter Date Patient Description Charges Credits Balance 9/30/2015 10/22/2015 10/22/2015 ■ Previous Balance 40.00 180.00 0.00 40.00 220.00 Account Total 220.00 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 220.00 0.00 0.00 0.00 0.00 Thomas J. Magna/M. Alvin Grayson-. EFTA01122974