STATEMENT Thomas J. Mae Alvin Grayson Mr. Jeff Epstein 9 East 71st Street New York NY 10021 payAg by cesSi art est the sawn you we wee h he nivitanc• bra ald Maui belay IA sierra int Vai Amu Cord* EN+ ON* Span Sc Code Dale Account 1/7/2015 10055 Remittance IMPORTANT - PLEASE COACH UPPER PORTION MO RETURN WITH YOUR RSUNTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 12/15/2014 12/15/2014 12/18/2014 Previous Balance . A . \ 40.00 180.00 425.00 q. S 0.00 40.00 220.00 645.00 Account Total 646.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the art of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 646.00 0.00 0.00 0.00 0.00 Thomas J. Moroni M . Alvin Grayson MI. EFTA01122975