HomeMy WebLinkAbout05-16-08
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Claim Against Decedent's Estate
ESTATE OF: Loreane Ensminger
Case# 21-2007-0363
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Living /DBA Golden Livingcenter - Camp Hill
PO BOX 180970 Fort Smith, AR. 72918-0970
The amount of the claim is $ 3149.61
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Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are tiUy8~
to the best of my knowledge and belief. ::J ~
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The basis of claim is: SEE A TT ACHED
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SIGNED ON: May 5, 2008
I SWEAR THIS STATEMENT IS CORRECT
Subscribed and sworn to before me
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TWYLA LENSING
Sebastian County
My Commission Expires
June 17, 2015
PO Box 180970
Fort SmiU.i, AR 72918
Phone: 479-201-2000
www.goldenliving.Q6r\1
Golden Livingcenter
P.O. Box 180970
Fort Smith, AR 72918
Itemized Resident Statement
Resident Name: Mailing Address: RESIDENT ACCOUNT #:
Thomas Ensminger 78682-03959-92128
Loreane Ensminger 5650 Charlton Way DATE PREPARED:
Mechanlcsburg, PA 17050 05/05/08
DATE I PERIOD COVERED DESCRIPTION DAYS/QTY CHARGES CREDITS
09/15/06 Cable Fee $11.50
10/12/06/10/31/06 Medicaid Private Portion 20 $1,311.63
10101/06 Cable Fee $11.50
11/01/06-11/30106 Medicaid Private Portion 30 $1,311.63
11/15/06 Cable Fee $11.50
12/01/06-12/31/06 Medicaid Private Portion 31 $1,311.63
01/01/07-01/12/04 Medicaid Private Portion 12 $1,311.63
11/22/06 Payment $2,122.16
04/30107 Payment $9.25
CHARGES CREDITS AMOUNT DUE
$5,281.02 $2,131.41 $3,149.61
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