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HomeMy WebLinkAbout11-07-11STATE OF Pennsylvania IN RE: ESTATE OF IN THE REGISTER OF WILLS EVELYN K CRAIG CUMBERLAND COUNTY CASE#: 21-10-1133 STATEMENT OF CLAIM American Infosource as agent for Health Management Associates 1. hereby presents fir filing against the above estate this statement of claim in the amount of $,_ 1 088.56 2. The basis for the claim is account number 8581002976 Unknown 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 Heauh 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 $ $10.60 -________ on Unknown 8. Please Serid paymeritS 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 2 day of November 2011 American Infosource as agent for Health Management Associates Claimant Name: Jon McCleske Claimant Signature: y~r ~~ - °` ~ ~ r-- t_i ~-- ~ _, C' ~ ~~ ; .. J ~} ~ ~ _~ ~ .C,'- CASE #:21-10-1133 IN RE ESTATE OF: EVELYN K CRAIG 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 t ' Affidavit. hrs 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 $_ $1088.56 evidenced by account number 8581002976 Further your affiant sayeth not Subscribed and sworn before me This 2 da~6f~Novemb~t NotaryPubiic /i ~-~= - American Infosource as agent for Health Management Associates By: One of its Authorized Rep atives: Printed Name: _ Jon McCleskey American Infosource as agent for Health M t Associates 3111111!//! .~``~ KING '''~~/. srq T, , P~..••0~~\~~• P.O. BOX 24[3894, Oklahoma City, OK 73124 t-a77-at 7-2ssa