STATEMENT Thomas J. Ma Alvin Grayson Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: RIM pptiN by cmeM ant as dm maim you we woo W M trationa tat Led Soul baw. Maskaard Amex Conl a Up Ms moon SILI wr Date Account 10/29/2015 3114 Remittance IMPORTANT • PLEASE DETACH UPPER PORT ONNO RETURN NTH YOUR REMITTANCE TO lusts:et:war roPROPERACCOUIR Date Patient Description Charges Credits Balance 9/30/2015 9/30/2015 9/30/2015 10/20/2015 Jeff Jeff Jeff Previous Balance AMERICAN EXPRESS 3,000.00 525.00 220.00 220.00 3,220.00 3,745.00 3,525.00 Account Total 3,525.00 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 Current 30 Days 60 Days 90 Days 120+ Days 3,626.00 0.00 0.00 0.00 0.00 Thomas J. MagnardlE. Alvin Grayson EFTA01122959