HomeMy WebLinkAbout03-24-14 ���Iden Enhancing lives through
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Claim Against Decedent's Estate
EsTaTE oF: REBECCA BENNER casF.No: 2i-2oi4-oo4�
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Living Center-WEST SHORE
PO BOX 180970
Fort Smith,AR. 72918-0970
The basis of claim is: Nursing Home Care
The amount of the claim is 6551.51
NOTE-If there is insurance pending on this account and the insurance fails to pay then amount will
become due privately.
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: March 5, 2014
Ge gia Tacke ollections Specialist II
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I SWEAR THIS STATEMENT IS CORRECT ,;�. � �, �
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www.goldenliving.com
PC� Box 180970
Fort Smith, AR 72918 • Phone: 877-367-1716 • Fax: 479-478-2625