HomeMy WebLinkAbout10-14-11STATE OF Pennsylvania
IN RE: ESTATE OF IN THE REGISTER OF W1LLS
HARRY F MITTEN CUMBERLAND COUNTY
CASE#: 21-11-0781
STATEMENT OF CLAIM
American Infosource as agent for Health Management Associates
1.
hereby presents for filing against the above
estate this statement of claim in the amount of $ $2.569.60
2. The basis for the claim is account number
UNK
8581128056
3. The tax identification number of the claimant is (if available)
which was open on
4. The name and address Of the Claimant 1S American Infosource as agent for Health Management Associates
P.O. BOX 248894, Oklahoma City, OK 73124
5. This claim IS NOT contingent
6. This claim IS NOT secured
7. The last payment made on the account was $ UNK on UNK
8. Please Send payments to American Infosource as agent for Health Management Associates
P.O. BOX 248894,
Oklahoma City, OK 73124
Please write the above account number on your check.
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.
Executed this 10 day of October 2011
American Infosource as agent for Health Management Associates
Claimant Name: Jon McCleskey
Claimant Signature:
State of Oklahoma ,County of Oklahoma
1N WITNESS WHEREOF, I have set my hand and notarial seal this
10 day of October 2011
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Notary Public ~ $„07643•=
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CASE #:21-11-0781
IN RE ESTATE OF: HARRY F MITTEN
AFFIDAVIT OF ACCOUNT
The undersigned, being first duly sworn deposes and states the follows:
1. Your Affiant is authorized by the Claimant as its Authorized Representative to make this
Affidavit.
2. Your Affiant has reviewed the account records of the Claimant with respect to the
decedent. Your Affiant is familiar with these records and accounts and reviews them as a
regular part of his/her duties.
3. The Decedent purchased merchandise and/or services in the amount of $ $2,569.60
evidenced by account number.
Further your affiant sayeth not
8581128056
American Infosource as agent for Health Management Associates
By: _
One of its Authorized Repre atives:
Jon McCleskey
Printed Name:
American Infosource as agent for Health Management Associates
P.O. BOX 248894, Oklahoma City, OK 73124
Subscribed and sworn before me 1-877-817-2554
This 10 day of October 2011 .
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