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 10F New York NY 10065 Ep Data Telephone: (212) 688-1090 .1 pay ng er r <red,t tare enter the amount yto aro WHM In Re mouttance bet, as ['Wow Mastercard Vtsa — Ames CAM S Statute S g Code Date Account 1/5/2011 9648 Remittance IMPORTANT . PLEASE CETACH UPPER PORTION MP RE1URN WITH YOUR REMITTANCE TO INSURE CREPT TO PROPER ACCOUNT Date 11/24/2010 11/22/2010 11/22/2010 11/22/2010 12/13/2010 12/13/2010 12/14/2010 12/14/2010 12/17/2010 ( `12/20!2010' 12/2015-113\ Patient Description Charges Credits Balance Previous Balance FMS with Bite wings Amalgam 1 Surface Perm. Amalgam 3 Surface Perm. Comp. W. Etch 1 Surface Comp. W. Etch 1 Surface Comprehensive Oral eval Adult Scale & Prophy MASTER CARD Porcelain W. Gold Crown 175.00 325.00 375.00 275.00 275.00 50.00 160.00 1,850.00 1,425.00 0.00 175.00 500.00 875.00 1,150.00 1,425.00 1,475.00 1,635.00 210.00 2,060.00 Account Total 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 212-688-1090. 2,060.00 Current 2,060.00 30 Days I 60 Days J 90 Days 0.00 0.00 0.00 120+ Days 0.00 Thomas J. Magnam D. D.S. Alvin Grayson D 0 S 7 West 51st Street 7th Floor Now York NY 10019 EFTA_R1_02010742 EFTA02686002