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IN THE ST ATE OF Pennsylvania
COUNTY OF Cumberland
IN RE: The Estate of
Ann Jones, Deceased
PROBATE FILE NO. 21-2005-980
ST ATEMENT OF CLAIM
The undersigned, being duly sworn, deposes and states that:
1. TSYS Total Debt management, Inc., whose address is Post Office Box 6700,
Norcross, Georgia 30091-6700, is the attorney-in-fact for WALMART
(hereinafter "Claimant"), whose Account Number is 6032203131068057 , and as attorney-
in-fact is authorized to submit this Statement of Claim on its behalf.
2. Claimant is the holder of a claim against the Estate of Ann Jones
deceased, the basis of which is the unpaid balance of charges incurred or authorized by the
deceased or on behalf of the deceased in the total amount of $1409.61 , as of the date of
the death of the deceased.
3. The said sum is now justly due this Claimant; and the claim is not contingent or
unliquidated.
4. No payment has been made thereon, and there are no offsets against the same,
and the same is not secured by judgment or mortgage upon or expressly charged on the real
estate of the deceased or any part thereof.
This
i--1+ \'\
day of
Sworn to and sUb:>cribed[before me this
-11- J.
L- day 0 / , 2006
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TSYS ~~t ~ft Management, Inc. ' 2006
As attorney-i~-fact for Claimant
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By: f,,'. 1:\ ! C- ft-'d ~ ~J
, \
Nyla Ja,C~bs 1
TSYS Pr~batlRepresentative
Copy mailed to attorney for Representative or to
Representative, if not represented by attorney.
this day of
TSYS Probate Representative
,2006
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Date:
fin" 11on.eS
Estate No.: ~ /-.i)~ 9fO
Ode of DeaL~: 10 /J (p / ;;;005'"
./ '
In L~e Estate of:
CUlM AGAlNST DFCEDENT'S ESTATE
1':.'1e ClG.i..rnant certiiies that there is due and owing by the Es.!de CJt:
/) h () _1/)11 e.s deceased.
ill accordance with the attached statement of account, h'1e S:":"'rrJ. of s,/ LI 09. t (
together with interest at the rate of
until paid.
from
On behalf or the claimant, I do solerrwly declare end affirm under LfJe penalties
or pefjurf Lhat LfJe LTliormation end representations made herein me true and correct
or L'1e best of DY l::nowledge, i...Tlio'.lTlation and beUeL
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(Sign -J+e lof Cloi_mont nr pprc:;nTl
authorized'to make vedication
on behalf of creditor)
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