HomeMy WebLinkAbout08-06-12Claim Against Decedent's Estate
ESTATE OF: Helen Brock Case# 21-12-00346
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Living/ CAMP HILL PITTSBURGH PA
PO BOX 180970
Fort Smith, AR. 72918-0970
The amount of the claim is $ 4249.00
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.
Signed on: July 19, 2012
I SWEAR THIS STATEMENT IS CORRECT
Subscribed and sworn to before me
! ~ 4
,~
Connie Furr Col ection Specialist
Ong `~" ~[-~
DYE L. VVHITB
,~ ~i4~TAItY PUBLIC
~_.,
,.. ,.. ._
ota Public ~~ ~ ~~~'~' ~ ~ ~,
l ^~~ ~ -,
~- ~,;. ,
f ~"•' _~
~ ~ ~~~ ~ ~r ~ l..a
My Commission Expires ~ '~ `~ ~ ..o ~ ~~ ~~'~
C..F ~-; _
"~ _~ cn O
h~