HomeMy WebLinkAbout07-07-15 livinga
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Claim Against DecedenYs Estate n ' m � � o
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ESTATE OF: Estella Russell � —' �, N o
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The undereignetl hereby presents for filing against ihe above estate this statement of claim and alleges:
Goltlen Livingcenter—West Shore
PO BOX 180970
Fotl Smith, AR. 72918-0970
The 6asis of claim is: Nursing Home Care �
Estafe Claim p-
The amount of ihe claim is�. $100373
NOTE-Ifthere is insurence pending on[his account and the insurance fails to pay[hen amount will
buome due priva[ely.
Under Denalties of perjury, I declare that I have reatl ihe foregoing,and ihe fads alleged are irue to�he
best of my knowledge and belief. Enclosetl is�he$10.00 filing fee.
Signed On: July 1, 2015
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Shyre 5 Iton, Collections Specialist
I SWEAR 7HIS S7ATEMENT IS CORRECT
Subscr d antl swom to before me - HiTA o'JNNELLV ��.
On � �} �U �� mca .isio�.« za �
XPIP� -11a I e� 2r1,��
Sebast en Goi rty
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Notary Public `
My Commission Expires ✓ /'U/W� V� � d� � �
PO Box �80970 • Fort Smith, AR 72918 �
877-367-1716 Fax: 479-478-2624 • www.GOldenLiving.com