HomeMy WebLinkAbout12-02-11STATE OF Pennsylvania
Ihi 1tE: ESTATE OF IN THE REGISTER OF WILLS
CLtNtON W MCDONALD CUMBERLAND COUNTY
CASE#: 21-ll-1159
STATEMENT OF CLAIM
American Infosource as agent for Health Management
1. .°e~,,;-~~ 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 8589506813 which was open on
UNK
3. .The name and address of the claimant is American Infosource as agent for Health Management Associates
P.O. BOX 248894, Oklahoma City, OK 73124
4. This claim IS NOT contingent
5. •This claim IS NOT secured
6. The last payment made on the account was $ $6,781.77 on UNK
7. Please Send payments t0 American Infosource as agent forHealth Management Associates
P.O. BOX 248894,
• Oklahoma City, OK 73124
1-877-817-2554
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 29 day of November 2011
American Infosource as agent for Health Management Associates
Claimant Name: Jon McCleske
Claimant Signature: ~
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CASE #:21-11-11.59
IN RE ESTATE OF: CLINTON W MCDONALD
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 $ $1,132.00
evidenced by account number 8589506813 .
Further your affiant sayeth not
American Infosource as agent for Health Management Associates
By:
~J One of its Authorized R~sentatives:
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
This 29 day of November ~ 2011
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Notary Public ~~1~'•
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1-877-81754
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