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 Acccrunt i 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 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