HomeMy WebLinkAbout02-22-07
IN THE PROBATE COURT FOR CUMBERLAND COUNTY, PENNSYLVANIA
PROBATE DIVISION FILE NUMBER 21-07-0038
IN RE: ESTATE OF HELEN JOHNSON, Deceased
STATEMENT OF CLAIM BY KELLY HOME CARE SERVICES.
\.D
o~.
:;.. ~ c5
c.__ J -
c= Th5mde;s~. hereby presents for filing against the above estate this statement of claims and
t_'___~. ~~;..o'(-.
c-~ '- ~ GO :.~~-.
-'.' . N ,.,.- ::-. ..,.~,
alleges: ty ~ i"
;:i:~ ffi [) 8= i~...'
~T~ 1. ~e bas~ the claim is Assisted Living: Services rendered to the deceased prior to his
=
c--.J
demise.
2. The amount of the claim is $4,189.50 which is the amount now due.
3. The social security or tax identification number of the claimant is 38-2110841.
4. The name and address of the claimant is: Kellv Services.Inc..999 W. Bisz Beaver Trov. MI
48084 and the name and address of the claimant's attorney, if any are as set forth below.
5. The claim ~ (is not) contingent or unliquidated. If contingent or unliquidated, the nature of
the uncertainty is
6. The claim ~ (is not) secured. If secured, the security consists of
Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true,
to the best of my knowledge and belief.
Dated this 12th Day of February, 2007 ~' ~ tJ. /J~
Cl an l<J
\/
#>
KELLY HOME CARE SERVICES, INC.
ESTATE OF HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
CLIENT:
HELEN JOHNSON
PAYMENT TERMS: DUE UPON RECEIPT
INVOICE NUMBER &
DATE CHECK NUMBER CD
11/22/2006
11/29/2006
SUB-TOTALS
STATEMENT
BRANCH NO. CUSTOMER NO.
5180 19001070
Kellv Home Care Services, Inc..
P.O. Box 828739
Philadelphia Pa. 19182-8739
BILLED TO : HELEN JOHNSON
This STATEMENT is submitted as a convenience to you so that you may verify open items.
If we have billed your insurance company, you may be responsible for charges not covered.
If payment has been made after the statement date indicated, please disregard. Thank you.
~Kelly Home Care_
SEllYICES
KELLY HOME CARE SERVICES, INC.
HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
SEND
PAYMENT
TO
KELLY HOME CARE SERVICES, INC.
P.O. BOX 828739
PHILADELPHIA, PA 19182-8739
PLEASE RETAIN THIS PART FOR YOUR RECORDS
CLIENT COPY
CORPORATE TAX 1.0.: 38-2110841
FRACTIONS OF AN HOUR ARE SHOWN IN DECIMALS
AS FOLLOWS: .25-15 MIN.; .50.30 MIN.; .75-45 MIN.
SERVICE SERVICE REGULAR OVERTIME
EMPLOYEE DESCRIPTION DATE HOURS RATE HOURS RATE AMOUNT
G WATKINS HHA HOURLY 11/13 12.50 18.00 225.00
G WATKINS HHA HOURLY 11/14 12.50 18.00 225.00
C JACKSON HHA HOURLY 11/14 10.50 18.00 189.00
C JACKSON HHA HOURLY 11/15 9.50 18.00 1 71 . 00
G WATKINS HHA HOURLY 11/15 3.25 18.00 58.50
G WATKINS HHA HOURLY 11/16 5.00 18.00 90.00
P PRICE HHA HOURLY 11/16 10.00 18.00 180.00
P PRICE HHA HOURLY 11/17 10.00 18.00 180.00
G WATKINS HHA HOURLY 11/17 10.50 18.00 189.00
P PRICE HHA HOURLY 11/18 10.00 18.00 180.00
nTHANK YOU FOR YOUR BUSINEssn
TERMS: PAYABLE UPON RECEIPT I CONTINUED ON NEXT PAGE
~----------------,--------------_.__._---_.__._--_._.-.-----.-.------.--.-.----.-.-.-----.-.-.----.-------.-----------
C\I
~ ~ Kelly Home Care
~ SE II Y I C ES- RETURN COPY WITH PAYMENT
m
<Xl
P
L
E
A
S
RPOO-00012 E
c.i
..s
en
Ql
o
.~
Ql
CIJ
Ql
:u
CJ
Ql
E
o
J:
~
Cii
~
C\I
o
o
C\I
o
.......................................................................... ......................................................................................................................
::::::i:!:::!:!:::!:::i:i:!:::::!:::II'II!:::i_I:i:::::::::!:::i:::!:::::!::::: .................." ,-, .......... ............... ...........
DATE CL I ENT NUMBER :':':':':':':':':':':':':jrtt.r'.....,r:':':':':':';';,:,;,:.:.
............. .... .............
............... ..... ..............
.. ....... .... .. .... ..............
~:f~:~:~t:~:~:~:~:~:~:::~::::::::::::::::::::;::~:~:::::::::::::::::::::::::::::::::~;~:~:~:~:~:~:~:~:~:~:~:~:;:
1 1 / 2 2 / 0 6 1 90 0 1 0 7 0 - 0 1 1 90 0 1 0 7 0 0 1 1 1 2 2 0 6 $ 1 , 9 5 7 5 0
CORPORATE TAX 1.0.: 38-2110841
o
E
T
A
C
H
H
E
R
E
. .. . . .. ..
:::::::I.:!::....I:~:~.I.:::.li:.~:II::I:I.:::I~:::.:1:::::.ll.I~.ltl...::I.li::.IIII:~I:II::I~I.II..:..I.::1::1::111:'1:11":::::1
KELLY HOME CARE SERVICES, INC.
P.O. BOX 828739
PHILADELPHIA, PA 19182-8739
HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
19001070011122060000010110001957508
~Kelly Home Care_
SERVICES
KELLY HOME CARE SERVICES, INC.
HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
SEND
PAYMENT
TO
KELLY HOME CARE SERVICES, INC.
P.O. BOX 828739
PHILADELPHIA, PA 19182-8739
PLEASE RETAIN THIS PART FOR YOUR RECORDS
CLIENT COPY
L
P
EMPLOYEE
COOLEY
PRICE
CORPORATE TAX 1.0.: 38-2110841
SERVICE
DESCRIPTION
HHA HOURLY
HHA HOURLY
SERVICE
DATE
11/18
11/19
FRACTIONS OF AN HOUR ARE SHOWN IN DECIMALS
AS FOLLOWS: .25-15 MIN.; .50-30 MIN.; .75=45 MIN.
REGULAR OVERTIME
HOURS RATE HOURS RATE
1 2 . 00 1 8 . 00
3.00 18.00
AMOUNT
216.00
54.00
"THANK YOU FOR YOUR BUSINESS"
TERMS: PAYABLE UPON RECEIPT
TOTAL AMOUNT
$
1 ,957 . 50
;: - --------~-~-~----~,----~-~-~-----~-~-~----~-~--~----~-~-~-----~-~-~-----~-~-~----~-~-~-~----~-~-~-~---~-~-~-~----~-~-~-~----~-~-~-~---~-~--
~ ~Kelly Home Care_
I SERVICES
pi
L I
El
At
sl
RPOO-00013 E I
t
Dl
E,
Tl
At
cl
HI
t
HI
E'
Ri
El
I
I
I
I
C\/
en
IX)
o
-=
vi
Q)
u
.~
Q)
en
Q)
:a
o
Q)
E
o
:J:
~
Qj
~
C\/
o
o
C\/
o
REFER TO PAGE 1 FOR REMITTANCE COUPON
~Kelry Home CareN
SERVICES
. KELLY HOME CARE SERVICES, INC.
:}{{{:DATE}}~:}} ???}
11/29/06 1900107001112906
HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
SEND
PAYMENT
TO
KELLY HOME CARE SERVICES, INC.
P.O. BOX 828739
PHILADELPHIA, PA 19182-8739
PLEASE RETAIN THIS PART FOR YOUR RECORDS
CLIENT COPY
CORPORATE TAX 1.0.: 38-2110841
FRACTIONS OF AN HOUR ARE SHOWN IN DECIMALS
AS FOLLOWS: .25-15 MIN.; .50-30 MIN.; .75=45 MIN.
SERVICE SERVICE REGULAR OVERTIME
EMPLOYEE DESCRIPTION DATE HOURS RATE HOURS RATE AMOUNT
L COOLEY HHA HOURLY 11/20 14.00 18.00 252.00
P PRICE HHA HOURLY 11/20 7.00 18.00 126.00
P PRICE HHA HOURLY 11/20 10.00 18.00 180.00
L COOLEY HHA HOURLY 11/21 12.00 18.00 216.00
P PRICE HHA HOURLY 11/21 10.00 18.00 180.00
L COOLEY HHA HOURLY 11/22 12.00 18.00 216.00
P PRICE HHA HOURLY 11/22 10.00 18.00 180.00
L COOLEY HHA HOURLY 11/23 12.00 18.00 216.00
P PRICE HHA HOURLY 11/23 10.00 18.00 180.00
P PRICE HHA HOURLY 11/24 10.00 18.00 180.00
"THANK YOU FOR YOUR BUSINESS"
TERMS: PAYABLE UPON RECEIPT I CONTINUED ON NEXT PAGE
-;:;---------------,--------------------------------------------------------------------------------
~ ~Kelly Home Care
~ S E R V ICE SN RETURN COpy WITH PAYMENT
m P
L
E
A
S
RPOO - 0001 4 E
u
-=
o
al
u
.~
al
en
~
as
Q
al
E
o
:I:
~
Gi
~
C\I
o
o
C\I
o
::::::i:::::::):::i:::::)::::::::::lBil::::III::::::::I:)::::i:::::::::::::::: ......................................................................................................................
DATE CL I ENT NUMBER :::::::::::::::::::::::::itiijif::::iiiiirir:::::::::::::::::::::::
....,...................... . .......... . ...........................
~~~~~~~~~~~~~~~~~r~~~~~~:;:~:::;::~;::~:::::::::;:~~~~~;:::;:::;:::::::::::::::::::::::~)~~~~~~~~r~~;~~~;~;~~
1 1 / 2 9 / 0 6 1 9 0 0 1 0 7 0 - 0 1 1 9 0 0 1 0 7 0 0 1 1 1 2 90 6 $ 2 , 2 3 2 0 0
CORPORATE TAX 1.0.: 38-2110841
D
E
T
A
C
H
H
E
R
E
.HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
1:II):'II:I:::::I:.:.:II.::I'.:~::.:I.i'.I:I.~.:I'!:I'11':.III.~~.i'..::'.':il.I::illl:.:'~I:I..:':I:i:::::.'11":II'..i:.:II.IIII~
KELLY HOME CARE SERVICES, INC.
P.O. BOX 828739
PHILADELPHIA, PA 19182-8739
19001070011129060000010110002232005
I:.Kelly Home Care~
SERVICES
.
KELLY HOME CARE SERVICES, INC.
HELEN JOHNSON
90 POPLAR AVENUE
NEW CUMBERLAND, PA 17070
SEND
PAYMENT
TO
KELLY HOME CARE SERVICES, INC.
P.O. BOX 828739
PHILADELPHIA, PA 19182-8739
PLEASE RETAIN THIS PART FOR YOUR RECORDS
CLIENT COpy
CORPORATE TAX 1.0.:
38-2110841
SERVICE
DESCRIPTION
HHA HOURLY
HHA HOURLY
SERVICE
DATE
11/24
11/25
FRACTIONS OF AN HOUR ARE SHOWN IN DECIMALS
AS FOLLOWS: .25-15 MIN.; .50-30 MIN.; .75-45 MIN.
REGULAR OVERT ME
HOURS RATE HOURS RATE
14.00 18 . 00
3.00 18.00
AMOUNT
252.00
54.00
L
S
EMPLOYEE
COOLEY
GORDON
"THANK YOU FOR YOUR BUSINESS"
TERMS: PAYABLE UPON RECEIPT
TOTAL AMOUNT
$
2,232.00
n;:;__-_-_-____-_._-_-____.,-______-_._____-_-_-_____________-____.___________-_-_-_-____-_-_-_-____-_-_-______________________ ____ __
~ I:.KeUy Home Care~
C\I I SERVICES
~ P,
L )
El
Al
s'
El
u RPOO-00015 I
.E D'
El
Tl
A,
Cl
H:
I
H'
El
Rl
E'
)
I
,
I
.
iii
CD
o
.~
CD
en
CD
ai
u
CD
E
o
:I:
~
Qj
:lo:::
C\I
o
o
C\I
o
REFER TO PAGE 1 FOR REMITTANCE COUPON