RADIOLOGY ASSOCIATES (KEY )-O26372663051-RADIOLOGY 1176 FIFTH AVE 1ST FLOOR 026546464530, NY 10017 PHONE: 212-241-6381 Name: JEFFREY EPSTEIN Card Number: <<xxxxxXxxXxx<xOO1* Card Exp Date: <Xx</xXxX< Card Not Present Transaction Type: AMEX SALE Merchant ID: 9334822 Transaction Amount: $50.00 Auth Code: 161404 Ticket #: 871 70621 Invoice #: 7206913 Date: 11/15/13 11:14:41 AM CARDMEMBER ACKNOWLEDGES RECEIPT OF GOODS AND/OR SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREIN AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CARDMEMBER's AGREEMENT WITH ISSUER \ eat a a SIGNATURE CUSTOMER COPY Mount Sinai Radiology Associates Date: HUW 2013 1176 Fifth Avenue, Box 1235 New York, NY 10029-6475 212-241-6381 ~ row: ella, Epstein s_95.0+ 95m tient: i Visit #: DOS: 2 [Amt. of Account A AY) WP) | ce CH ane RR || am Cash Check # Operator's Signatu 01- 02225 EFTA00313837