HomeMy WebLinkAbout06-09-08gc ~Iden
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Claim Against Decedent's Estate
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Case# 2107841
ESTATE OF: Harold Major
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Living IDBA Golden Livingcenter -GGNSC Gettysburg LP
PO BOX 180970 Fort Smith, AR. 72918-0970
The basis of claim is: SEE ATTACHED
The amount of the claim is $ 2429.85
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.
SIGNED ON: May 19, 2008
I SWEAR THIS STATEMENT IS CORRECT
My Commission Expires
08
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Yvonne Swartz
,~'La1l.f~".,; TWYLA L~N91NG
a,; ~T~~.;*. s~bflatian County
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,~,gKArJ~~' ;viy C7mmis~ion expires
Juns 17, 2015
P,O. Box 180970
Fort Smith, AR 72918
Phone: 479-201-2000
www.goldenliving.com
Subscribed and sworn to before me
Golden Livingcenter
P.O. Box 180970
Fort Smith, AR 72918
Itemized Resident Statement
Resident Name: Mailing Address:
Ella Morin RESIDENT ACCOUNT #:
85386-03926-91670
Harold Major 106 Centerville Road
Newville, PA 17241 DATE PREPARED:
05/19/08
DATE I PERIOD COVERED DESCRIPTION DAYS /QTY CHARGES CREDITS
01130/07-01131/ I nsurance Co-Pa 2 $1,096.94
02/01107-02128107 Insurance Co-Pa 28 $2,170.47
02/07/07 Barber 1 $10.00
03/01107-03/02107 Insurance Co-Pa 2 $162.44
03/03/07-03/07!07 Room Char e 5 $1,028.71
03/07/07 Barber 1 $10.00
03/07 Refund $1,231.30
03/12/07 Pa ment $10.00
03/05/07 Pa ment $3,250.00
03/30/07 Pa ment $20.01
CHARGES CREDITS AMOUNT DUE
$5,709.86 $3,280.01 $2,429.85
Page 1 of 1
gc ~Iden
May 19, 2008
Probate Court
1 Courthouse Square
Carlisle, PA 17013
To whom it May Concern
Enclosed please find an itemized statement and a claim form to be used to file a claim
against the estate of Harold Major. Mr. Major incurred these charges while a resident in
our facility, Golden Living center, GGNSC Gettysburg LP. Please find enclosed a check
for the amount of $10.00 for the filing fee.
If you should need additional information or have questions regarding this please feel
Free to contact me at 877-823-8375 ext 2270 Monday thru Friday from 8:00 to 5:00 PM
Central Time.
Sincerely,
Rita Donnelly
Healthcare Collector
Golden Living Center
P.O. Box 180970
Ft. Smith, AR 72918
RDC
Encl:
CC: Client's File # 85386
P.O.Box180970
Fort Smith, AR 72918
Phone: 479-201-2000
www.goidenliving.com