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Claim Against Decedent's Estate
ESTATE OF: Cora Baney
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Livingcenter—West Shore
PO BOX 180970
Fort Smith,AR. 72918-0970
The basis of claim is: Nursing Home Care
Estate Claim#-2015-00014
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The amount of the claim is: $2908.43 � q �
ca .a =�r �'
NOTE-lf there is insurance pending on this account and the insurance fails to p�tl�n�nou�i.�ill cj c'm�
become due privately. '' �" � c i ��.,
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Under penalties of perjury, I declare that I have read the foregoing, and the facts�ll�e�are�to�'� q
best of my knowledge and belief. Enclosed is the$10.00 filing fee. `t' � 1 �''�
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Signed On: March 30, 2015
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Shyra elton, Collections Specialist
I SWEAR THIS STATEMENT IS CORRECT
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Subscr' and sw rn to before me
� / ��rA DONNELLY
� ' MY COMMISSION#123ipG4G ��
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On ��l ,. ` EXPIkES:March 26,� '
����;s Sebastiar, �019
'���a, County
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Notary Public
My Commission Expire
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PO Box 180970 • Fort Smith, AF;� ���?5ih!I�:3
877-367-1716 Fax: 479-478-2624 • www.Gc�l�ieri'L._iving.com