HomeMy WebLinkAbout04-23-12IN RE: ESTATE OF
SAMUEL R CALABRETTA
STATE OF Pennsylvania
IN THE REGISTER OF WILLS
CUMBERLAND COUNTY
CASE#: 21-11-1306
STATEMENT OF CLAIM
American Infosource as agent for Health Management hereby presents for filing against the above
1.
estate this statement of claim in the amount of $ $1,760.00
2. The basis for the claim is account number
8/6/2011
8589502977 which was open on
3. The name and address Of the Claimant 1S 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 $ $6,918.72 on UKN
']. Please Serid payments to 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 19 day of Anril 2012
American Infosource as agent for Health Management Associates
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Claimant Name: Jon Mc
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Claimant Signature: •- . -~-,
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CASE #:21-11-1306
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.
3. The Decedent purchased merchandise and/or services in the amount of $
evidenced by account number 8589502977
Further your affiant sayeth not
$1,760.00
American Infosource as agent for Health Management Associates
Subscribed and sworn before me
This 19 day
Notary Public
SAMUEL R CALABRETTA
By:
One of its Authorized Repr entatives:
Jon McCleskey
Printed Name:
American Infosource as agent for Health Management Associates
P.O. BOX 248894, Oklahoma City, OK 73124
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_ .EXP. U8/3U/15 -
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