HomeMy WebLinkAbout02-08-12i ,z
In the Estate of: SANDRA GENSLER
Register of Wills for:CUMBERLAND COUNTY
Estate No. /~.~""" ~~ "' ~Q~f
Date: 0 q~ 0 ~ / ~ 1
CLAIM AGAINST DECEDENT'S ESTATE
The claimant certifies that there is due and owing by the decedent in ordanc~:
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with the attached statement of account or other basis for the claim the su
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$4928.97, account number: 4000094636. ~~~ O°
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I solemnly affirm under the penalties of perjury that the contents of the oing u,
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claim are true to the best of my knowledge, information, and belief.
UNIVERSITY SPECIALTY HOSPITAL
Name of Claimant
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Name and dle of Person Signing Claim
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Signature of claimant person authorized to make
verifications on behalf of claimant
1220 A EAST JOPPA ROAD, SUITE 223
Address
TOWSON. MD 21286
(410) 828-1322
Telephone Number
CERTIFICATE OF SERVICE
I herby certify that on this _~day of 0. (month), ~/~(year), I ^ delivered or
X mailed, first class postage prepaid a copy of the foregoing Claim to personal representative,
9 EAST LAUMAN ST ,MOUNT HOLLY SPRING , PA 17065
(name and address}
Signature of Claimant
Instructions:
1. This form may be filed with the Register of Wills upon payment of the filing fee of $3.00 provided by
law. A copy must also be sent to the personal representative by the claimant.
2. If a claim is not yet due, indicate the date when it will become due. If a claim is contingent, indicate
the nature of the contingency. If a claim is secured, describe the security.
RW 1128_ IIIIIII~IN~II~11N~~I~II~I~~nI~~IIIIIIII 1698640_ESTCLPRJ
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