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HomeMy WebLinkAbout12-02-11STATE OF Pennsylvania IN RE: ESTATE OF IN THE REGISTER OF WILLS RICHARD B MILLER CUMBERLAND CASE#: 21-11-1203 STATEMENT OF CLAIM American Infosource as agent for Health Managemeat 1. .--,~_;-gym hereby presents for filing against the above estate this statement of claim in the amount of $ $1,320.00 2. The basis for the claim is account number 8589507153 which was open on IJ1yK 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 $ $3,844.97 on UNK ~. Please Send paymeritS t0 American Infosource as agent for Health 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 McCleskey Claimant Signature: ~ rr,,i ~" tlx 1\J ~~~~ -iC ~~ tC' COUNTY ~ `~- ~'` ~~ i"t'# CASE #:21-11-1203 IN RE ESTATE OF: RICHARD B MILLER 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 $ $1,320.00 evidenced by account number 8589507153 , Further your affiant sayeth not American Infosource as agent for Health Management Associates By: ~ One of its Authorized Representatives: Printed Name: Jon McCleskey American Infosource as agent for Health Management Associates P.O. BOX 246894, Oklahoma City, OK 73124 Subscribed and sworn before me This 29 day of November ~ 2011 ~ ~T Notary Public ~ ~~.1~~6 1~ ~~ otF 1-877-61754 as ~ ~ ~~ ~ r7^s x ~ _ ~-z i r "~ ~ t't't "'~ D .» F ~~ t[+