HomeMy WebLinkAbout12-29-09In the Estate of:
~,.
Estate No.Z~"~., ~C~~ d~~/~
~ ~ 6` ,. ~ ~ .n ~~ Date _ -~ ~ . -~ ~ ,
CLAIM AGAINST DECEDENT'S ESTATE
The claimant certifies that there is due and owing by the decedent in accordance
with the attached statement of account or other basis for the claim the sum of
~ ~-`S ~, . O ~ .
I solemnly affirm under the penalties of perjury that the contents of the foregoing
claim are true to the best of my knowledge, information, and belief.
Pharmacare of Cumberland
Name of Claimant
~° Signature of claimant or person authorized to make
verifications on behalf of claimant
~Tami Shober, Billing Clerk 3 Commerce Drive
1,,,~, Name and Title of Person Signing Claim Address
'~` ~ ~'' a~ Cumberland, MD 21502
,.,_- .,
r `3 ~ ` ' 2
tJa.: .. Cr? ~
~, ~ ~, _ „ (301) 723-2419
- .-
r _;
GL ~>..-~ //..~, Telephone Number
... .....4 I._....
~_ ~ , ~,.. ^ r^I .
L. 7_ Q'~t 4y
' i a._J .. °~ .
~:~; ~ ~ ` . CERTIFICATE OF SERVICE
o ~--
~:~~ ~ ~
derby certify that on this ~_ day of __~ ~ ~..'bef~' (month), C7~ (year), I ^
delivered or ailed, first class, postage prepaid, a copy of the foregoing Claim to the personal
representative, ~.-.~~o ~~'' ~- ~~ c~~- ~
Instructions:
1. This form may be filed with the Register of Wills upon payment of the filing fee of $3.00 provided by
law. A copy must also be sent to the personal representative by the claimant.
2. If a claim is not yet due, indicate the date when it will become due. If a claim is contingent, indicate
the nature of the contingency. If a claim is secured, describe the security.
RW 1128
2008