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Home My WebLink About11-14-11STATE OF Pennsylvania IN RE: ESTATE OF IN THE REGISTER OF WILLS ESTHER A DYARMAN CUMBERLAND COUNTY CASE#: 21-11-1094 STATEMENT OF CLAIM American Infosource as agent for Health Management Associates hereby presents for filing against the above estate this statement of claim in the amount of $ $250.00 2. The basis for the claim is account number 7/812011 8589500528 which was open on 3. The tax identification number of the claimant is (if available) , 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 $ $5,790.51 on Unknown g. Please send paymeritS t0 American Infosource as agent for Health Management Associates P.O. BOX 248844, Oklahoma City, OK ?3124 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 8 day of November 2011 American Infosource as agent for Health Management Associates Claimant Name: Jon McCleskey Claimant Signature: n __ ~ ~_~ ~n~~ e-; ~ ~~ ~ -° _ -r _,. U rj ~+. ~' t.~? C' -~ , a_j ':7 ~, -- ` ,_~ ,. .~~ _'_ r` j ~ ..~ ~l ~.•-~ '.s'i CASE #:21-11-1094 IN RE ESTATE OF: ESTHER A DYARMAN 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 ofhis/her duties. 3. The Decedent purchased merchandise and/or services in the amount of $ $250.00 evidenced by account number 8584500528 , Further your affiant sayeth not American Infosource as agent for Health Management Associates By: One of its A uthorized Repre fives: Jon McCleskey Printed Name: American I nfosource as agent for Health Management Associates P.O. BOX 248894, Oklahoma City, OK 73124 Subscribed and sworn before me 1-877-817-2554 This 8 day of November 2011 n _~j ~, ~ ~ ~ : - - - o ' 0o sns Notary Public ~ # _ ~` , ~ ~ `~ --- O f ~' ~~ ~~' J C - Jy^ ~t` 'ry p~ F ~ TJ D C.?"i ~,~ Q ~ t.-;