STATEMENT

STATEMENT Thomas J. Mae Alvin Grayson Mr. Jeff Epstein 9 East 71st Street New York NY 10021 payAg by cesSi art est the sawn you we wee h he nivitanc• bra ald Maui belay IA sierra int Vai Amu Cord* EN+ ON* Span Sc Code Dale Account 1/7/2015 10055 Remittance IMPORTANT - PLEASE COACH UPPER PORTION MO RETURN WITH YOUR RSUNTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 12/15/2014 12/15/2014 12/18/2014 Previous Balance . A . \ 40.00 180.00 425.00 q. S 0.00 40.00 220.00 645.00 Account Total 646.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the art of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 646.00 0.00 0.00 0.00 0.00 Thomas J. Moroni M . Alvin Grayson MI. EFTA01122975 STATEMENT Thomas J. Ma Alvin Grayson Mr. Jeff Epstein 9 East 71st Street New York NY 10021 TelephomIMM II paying by ail OWL INN M inset yaw on IMMO r h• erittana box aid re eta Sent Phieletainf IAN Mtn Cards Exp OMs Sonata Sig CoSe Date Account 7/1/2015 10055 Rernittanco &PORTANT • PLEASE DETACH UPPER PORTION MO FtETURN WIN YOUR RECNCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/3/2015 ce 0.00 6/16/2015 180.00 180.00 6/16/2015 40.00 220.00 6/16/2015 180.00 380.00 6/16/2015 750.00 1,130.00 006669 f(“' de a l a -tic_ 061- 42. )1 -7 f I S (1SP Account Total 1,130.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete this statement, or call the office atiliallOr art of Current 30 Days 60 Days 90 Days 120+ Days 1,130.00 0.00 0.00 0.00 0.00 Thorn's J. Martini MI. ANIn GraYsonS EFTA01122976 STATEMENT Thomas J. Ma . Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Spaying by asa cat ever Pe anon) YOU WO PON) In h isMum Goa ad R out WM. Mate WO Ws. AMP, Cads Tap Dais Wars Sp Cc* Date Account 3/30/2016 10055 RomIttanoo INPORTANT - PLEASE DETACH UPPER PORTION AND RERAN WIN YOUR REACTANCE 70 INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/2/2016 Pre • ... ;.....nce 0.00 3/21/2016 40.00 40.00 3/21/2016 180.00 220.00 3/21/2016 450.00 670.00 3/21/2016 160.00 830.00 r C ( 6 ‘ I ( ° Account Total 830.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards) You may complete and return the to • part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 830.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl S Min Grayson M. EFTA01122977