Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. STATEMENT Telephone: a 7 West 51st Street I paying by creditcard, enter the amount YOU are paying in the remittance box and 7th Floor : mes Visa Amex New York NY 10019 Card# Exp Dale Signature __ _ Sig Code Mr Jeff Epstein | —iDate Account _ P.O. Box 806 12/10/2013 10542 New York NY 10150 — Remittance IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 0.00 12/10/2013 60.00 60.00 12/10/2013 180.00 240.00 12/10/2013 50.00 290.00 12/10/2013 150.00 440.00 12/10/2013 15.00 455.00 12/10/2013 1,100.00 1,555.00 12/10/2013 24.00 1,579.00 Account Total 1,579.00 We accept credit cards! You may complete ae” part of this statement, or call the office a Current 30 Days | 60 Days 90 Days | 120+ Days 1,579.00 0.00 0.00 0.00 0.00 Thomas J. MagnaniD.0.S. Alvin GraysonD.D.S. 7 West 51st Street 7th Floor New York NY 10019 FY EFTA00313303