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HomeMy WebLinkAbout04-23-12 STATE OF Pennsylvania IN RE: ESTATE OF IN THE x~cISTER of wi>/>rs DENITA LYNNE ADAMS CUMBERLAND COUNTY CASE#: 21-] 2-0299 STATEMENT OF CLAIM American ]nfosource as agent for Health Management 1, hereby presents fore filing against the above estate this statement of claim in the amount of ~ 5250.00 2. The basis for the claim is account number 8589517461 which was open on 2/9/2012 3. The name and address of the claimant is American tnfosoarce as agent for Heedth Management Aasociates P.O. BOX 248594, 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 $ $6,594.00 on UKN 7. Please send payments to American Infosource as agent for Health Management Associates P.O. BOX 248894, Oklahoma City, OK 73124 t-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 16 day of April 2012 American Infosource as agent for Health Management Associates Claimant Name: Jon McCleskey Claimant Signature: `~' 7-e p ~ r,~ ~ _ ; ~j r. ~ r ~~ ~n YrY7~ ti W .. , ... ~ ~ ~ ;, g ~ _~: . -~ . ~ ' x~ r,t _ = m n ~, ~•~ O - a n CASE #:21-12-0299 IN RE ESTATE OF: DENITA LYNNE ADAMS 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. $250.00 3. The Decedent purchased merchandise andfor services in the amount of gl evidenced by account number 8589517461 . Further your affiant sayeth not American Infosource as agent for Health Management Associates By: Y~~~ One of its Authorized Reptesc; atives: .Jon McCleskey Printed Name: American Infosource as agent for Health Management Associates P.O. BON'. 248894, Oklahoma City, OK 73124 Subscribed and sworn before me l- ran-an-zssa 16 ril 2012 ~~~"~~ D~ Kl/y "'o,. day of `~ gyp- , .......... C S #11 ~~~9U 15 s~_ Public = ~=. EXP' ~ - ' G :' O ., y ............ .. STATE OF Pennsylvania IN RE: ESTATE OF IN THE RECtsTeHOFwnt.t,s DENITALYNNEADAMS CUMBEIILAND COUNTY CASE#: 21-12-D299 STATEMENT OF CLAIM American Infosource as agent for Health Management i , hereby presents 1'or filing against the above estate this statement of claim in the amount of $ $250.00 2. The basis for the claim is account number 8589577461 which was open on 2!9/2012 3. The name and address of the claimant is American Infosource as agent for Heealth 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 $ $6,594.00 on UHN ~. please send 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 16 day of April 2012 American Infosource as agent for Health Management Associates Claimant Name: JonMeCleskey Claimant Signature: r of ~ li') °; ..} N V M N r .- (' ~ 0. J ' ~ © N ~ c; tt , ty O VJ N 'R: CJ N N • or- ~ o. r ~ ~ ~ O N O ' 3 W _, O ~ (y SwF=l7f G H ~ ~ ~ 7 w~Oa tri ~ ~ ~ ~ (tit zZ~~ iP ~40 ~ (7 .~•q m ~ 1..~ L= ~•... v ,1 s ; S ~ 0. = U {~QJ U~ N 4 M r O z ~~ a ~ X ~ m= g ~ ~OsG =a0