HomeMy WebLinkAbout02-13-12~~.~~% -C;rjc~
STATE OF Pennsylvania
IN RE: ESTATE OF IN THE REGISTER OF WILLS
THELMA P KUHN CUMBERLAND COUNTY
CASE#: 10099
STATEMENT OF CLAIM
American Infosource as agent for Health Management
I' ~~~~ • • hereby presents for filing against the above
estate this statement of claim in the amount of $ $5,624.74
2. The basis for the claim is account number
Unknown
8589418122 which was open on
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 $ $1,024.00 on Unknown
7. Please Send payments 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 perj ury, I declare that I have read the foregoing, and the facts alleged are true, to the
best of my knowledge and belief.
Executed this 9 day of February 2012
American Infosource as agent for Health Management Associates
Claimant Name: Jon McCleske
Claimant Signature:
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CASE #:100993
THELMA P KUHN
IN RE ESTATE OF:
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.
$5,624.74
3. The Decedent purchased merchandise and/gsg9418122 the amount of $___
evidenced by account number
Further your affiant sayeth not
American Infosource as agent for Health Management Associates
By:
One of its Authorized Repres ves:
Jon McCleskey
Printed Name:
American Infosource as agent for Health Management Associates
P.O. BOX 248894, Oklahoma City, OK 73124
1-877-817-2554
Subscribed and sworn before me
This 9 day of February 2~u,,.
i~~lr V/l~
Notary Public