STATEMEN 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 1OF New York NY 10065 1111)-1 IC/\_ Telephone: (212) 688-1090 II paying by credit cant ant too amount you ant ph+n; on IM rempnanco box and hi out tdow Manned Visa Amens Card N &gnaw.* So Con Fip On Date Account 12/14/2010 9648 Remittance IMPORTANT. PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK RES/TRANCE TO iNSVRE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/24/2010 Previous Balance 0.00 11/22/2010 Renata FMS with Bite wings 175.00 175.00 11/22/2010 Renata Amalgam 1 Surface Perm. 325.00 500.00 11/22/2010 Renata Amalgam 3 Surface Perm. 375.00 875.00 12/13/2010 Renata Comp. W. Etch 1 Surface 275.00 1,150.00 12/13/2010 Renata Comp. W. Etch 1 Surface 275.00 1,425.00 Account Total 1,425.00 We accept credit cards! You may complete and return the top part of this statement, or call the office at 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 1,425.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA01155767