HomeMy WebLinkAbout01-09-06
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Claim Against Decedent's Estate
Estate Of: William Sellers
Case #717-240-6345
The undersigned hereby presents for filing against the above estate this statement of
claim and alleges:
Beverly Enterprises/West Shore Health & Rehab Center
P.O. Box 180970 Fort Smith, AR. 72918
The basis of claim is: See Attached
The amount of the claim is $803.56
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 O~06
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Clai ant Sandra Burnett
I Swear this statement is correct
On
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TWYLA LENSING
Sebast!an County
My CommIssIon Expires
June 17, 2015
Subscribed and sworn to before me
My Commission Expires ~ -J 1-?-D 15
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P.O. Box I S0970
Fort Smith, AR 72918-0970
479.201.2000. S77.S2,'.S37S
www.heverlycares.o)m
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BEVERLY ENTERPRISES
POBOX 180970
FORT SMITH ARKANSAS 72918
Itemized Resident Statement
RESIDENT ACCOUNT#:
71078-00285-99817
William Sellers
01/06/06
DATES OF SERVICE DESCRIPTION DAYS I aTY CHARGES CREDITS
01/20/04 Barber 1 $9.00
03/02/04 Barber 1 $9.00
04/17/04-04/20/04 Room Charge 4 $300.00
05/07/04 Barber 1 $9.00
06/03/04 Room Charge 1 $75.00
07/06/04-07/31/04 Room Chan:Je 26 $4,134.00
07/16/04 Barber 1 $9.00
07/16/04-0 (/17/04 Telfa Non Stick PA 2 $2.00
07/14/04-07/15/04 Pillow Paws Feet 2 $4.70
07/31/04 Curex 4x4 8ply 1 $0.14
07/14/04 Geri Glove Larqe 1 $36.92
07/31/04 Mepore 4x4 1 $0.44
08/01/04-08/31/04 Room Charqe 31 $4,929.00
08/02/04 Prep Site Wipes 1 $0.12
08/02/04-08/30/04 Curex 4x4 8ply 2 $0.28
08/06/04-08/13/04 First Quality Briefs 40 $23.20
08/02/04-08/08/04 Duoderm Ex\Thin 3 $10.08
08/30/04 Mepore 4x4 1 $0.44
09/01/04-09/30/04 Room Charqe 30 $4,929.00
09/25/04-09/27/04 Gauze Sponqe 2x2 2 $2.00
09/18/04-09/25/04 Telfa Non Stick PA 10 $10.00
09/21/04 Svringe, Luer Sri 1 $1.00
09/18/04 Curex 4x4 8ply 1 $0.14
10/01/04-10/31/04 Room Charqe 31 $4,929.00
10/19/04 Barber 1 $9.00
10/28/04 First Quality Briefs 18 $18.72
10/08/04-10/21/04 First Quality Pant Insert 54 $31.32
11/01/04-11/30/04 Room Charge 30 $4,929.00
12/01/04-12/26/04 Room Charqe 26 $4,134.00
12/27/04-12/31/04 Private Portion 5 $803.56
12/03/04-12/23/04 First Quality Pant Insert 74 $42.92
01/01/05-01/31/05 Private Portion 31 $819.56
02/01/05-02/28/05 Private Portion 28 $819.56
03/01/05-03/14/05 Private Portion 14 $809.56
04/01/05-04/25/05 Private Portion 25 $809.56
05/11/05-05/31/05 Private Portion 21 $809.56
06/01/05-06/30/05 Private Portion 30 $809.56
CHARGES CREDITS TOTAL AMOUNT DUE
$34,269.34 $0.00 $34,269.34
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January 4,2006
Register of Wills
1 Courthouse Square
Carlisle, P A 17013
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Whom It May Concern
Enclosed please find an itemized statement and a claim form to be used to file a claim
against the estate of William Sellers. Mr. Sellers incurred these charges while a resident
in our facility, West Shore Health & Rehab Center. Please find enclosed a check for the
amount of $10.00 and a self addressed stamped envelope.
If you should need additional information or have questions regarding this please feel
free to contact me at 877-823-8375 ext 2270 Monday thru Friday from 8:00 to 5:00 PM
Central Time.
Sincerely,
Rita Donnelly
Healthcare Collection
Beverly Enterprises Ine
PO Box 180970
Ft. Smith, AR 72918
RDC
encl:
ee: Client's File
71078
1'.0. Box 1 X0970
Fort Smith, AR 7291 X-0970
479.201.2000. X77.X2.1.X375
www.hevcrlycares.cllm
DATE/PERIOD COVERED DESCRIPTION DA YS/QTY CHARGES CREDITS
07/01/05-07/31/05 Private Portion 31 $809.56
08/01/05-08/31/05 Private Portion 31 $809.56
09/01/05-09/30/05 Private Portion 30 $809.56
10/01/05-10/31/05 Private Portion 30 $809.56
11/01/05-11/21/05 Private Portion 21 $809.56
04/05/04 Payment $2,742.93
08/10/04 Payment $6,400.27
09/17/04 Payment $5,314.92
10/14/04 Payment $4,942.14
11/10/04 Payment $4,961.20
12/15/04 Paym ent $4,000.00
01/20/05 Paym ent $226.96
02/15/05 Payment $1,639.12
03/14/05 Payment $809.56
04/12/05 Payment $809.56
06/14/05 Payment $1,619.12
07/12/05 Payment $809.56
08/10/05 Payment $809.56
09/12/05 Payment $809.56
11/15/05 Payment $1,619.12
BALANCE FORWARD CHARGES CREDITS TOTAL AMOUNT DUE
$34,269.34 $4,047.80 $37,513.58 $803.56
William Sellers
C\O Michael Seifried
St Johns Lutheran Church
44 West Main Street
Shiremanstown, PA 17011