HomeMy WebLinkAbout10-14-11STATE OF Pennsylvania
IN RE: ESTATE OF IN THE REGISTER OF WILLS
RICHARD L LISSNER
CUMBERLAND COUNTY
CASE#: 21-11-0966
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 $ $1,132.00
2. The basis for the claim is account number
UNK
3. The tax identification number of the claimant is (if available)
which was open on
4. The name and address Of the claimant IS 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 $ $8,157.66 on UNK
g. Please Serid payments t0 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
IN WITNESS WHEREOF, I have set my hand and notarial seal this n • __ _?~~
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10 day of October 2011 -C7
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8589499730
CASE #:21-11-0966
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IN RE ESTATE OF• RICHARD L LISSNER =: ~~ ~
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AFFIDAVIT OF ACCOUNT - -• •~ C.7
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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 $
evidenced by account number 8589499730
Further your affiant sayeth not
$1,132.00
American Infosource as agent for Health Management Associates
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One of its Authorized Representative .
Jon McCleskey
Printed Name:
American Infosource as agent for Health Management Associates
Subscribed and sworn before me
This 10 day of October 2011
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Notary Public ? ~ # 110078A3
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P.O. BOX 248894, Oklahoma City, OK 73124
1-877-817-2554