HomeMy WebLinkAbout04-23-12STATE OF Pennsylvania
IN RE: ESTATE OF IN THE REGISTER OF W[LLS
BERNARD 5 MEALS CUMBERLAND COUNTY
CASE#: 21-12-0291
STATEMENT OF CLAIM
American Infosource as agent for Health Management
I , , e~_;~,,,- hereby presents for filing against the above
estate this statement of claim in the amount of $ $400.00
2. The basis for the claim is account number 8589518329 which was open on
2/21/2012
3. The Hanle and addrOSS 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 $ $5,085.86 on UKN
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 16 day of April 2012
American Infosource as agent for Health Management Associates
Claimant Name: Jon McCleskev
Claimant Signature:
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CASE #:21-12-0291
IN RE ESTATE OF: BERNARD S MEALS
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 8589518329
Further your affiant sayeth not
American Infosource as agent for Health Management Associates
By: ~
One of its Authorized Represen es:
Jon McCleskey
Printed Name:
American Infosource as agent for Health Management Associates
Subscribed and sworn before me
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This 16 d Apr>< ~.~ n. Kt/~i~ „~,;
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110.,~~y4~ /-
Notary Public ~ ~y.4 ~~
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$400.00
P.O. BOX 248894, Oklahoma City, OK 73124
1-877-817-2554
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