EFTA00313837.pdf

RADIO Loa -v. ASSOCIATES (KEY)-026372663051-1RACtIOLOGY 1176 FIFTH AVE 1ST FLOOR 026546464530, NW 10017 RI -IONIC: 21 2-241 -6381 Name: JEFFREY EPSTEIN Card Number: >00000000000001" Card Ekn Data: >C></>CX Card Not Present Transaction Type: AMEX SALE Merchant 10: 9334822 Transaction Amount: $50.00 ^tin, Code: 161404 Ticket tt: 87170621 Invoice tit: 720691'3 [Date: 11/15/13 11:14:41 AM CAFt0IVIEMBEFt ACKNOWLEDGES rxeceurrr OF GOODS "NJO/OFt SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREIN ANJO AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CAIROMEIVIESEFt's AGREEMENT WITH ISSUER SIGNATURE CUSTOMER COPY Mount Sinai Radiology Associates Date: 15 11/41Dv OiLc) 1176 Fifth Avenue, Box 1235 New York, NY 10029-6475 212-241-6381 01- 02225 Rr eived from: tannQ l £PSin $ 25 tb+DVY) datient: ((1,0 0;(\ e mrst: tigk ars e ll tO6Qi3 I DOS: DH ft .4. DO LS Amt. of Accoun Amt. Paid Balance Due (2) /o CC Cash Check # Operators Signatur 1. EFTA00313837