HomeMy WebLinkAbout04-25-06
In the estate of:
RALPH L. SMITH
Date: 4-12-06
Estate No: 21-2006-0039
Date of Death:
1?/?O/05
CLAIM AGAINST DECEDENT'S ESTATE
The Claimant certifies that there is due and owing by the RALPH L. SMITH
deceased,
in accordance with the attached statement of account the sum of $ 642 . 99
together with interest at the rate of from
until paid.
On behalf of the claimant I do solemnly declare and affirm under the penalties
of perjury that the information and representations made herein are true and correct
of the best of my knowledge, information and belief.
KOHL'S DEPT. STORE
Name of Claimant
Mark E. Bennett, Agent
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Address of Claimant
Signature of Claimant or person
authorized to make verification
on behalf of creditor
9441 LBJ Freeway
Lock Box 30
Dallas, TX 75243
Address
Phone Number
972-644-6360
Phone Number
FILED:
THIS FORM MAY BE FILED WITH THE ORPHANS COURT UPON PAYMENT OF A
FILING FEE OF $10.00. A COpy MUST ALSO BE SENT TO THE PERSONAL
REPRESENTATIVE.
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PROBATE COURT
Cumberland County, State of Pennsylvania
Ralph L. Smith, Deceased
Case #21-2006-0039
Proof of Mailinq
I mailed the creditors claim to the fiduciary (and attorney, if applicable) as
follows:
I deposited a copy/copies of the claim with the United States Postal Service in
a sealed envelope with the postage fully pre-paid. I used first-class mail. I
am employed in the county where the mailing occurred. The envelope(s) was/were
addressed and mailed as follows:
Ms. Cheryl Smith
c/o Keith O. Brenneman, Esq.
44 W. Main St.
Mechanicsburg, PA 17055
Date of Mailing: ~~tr
County of Mailing: Dallas, Texas
I declare under penalty of perjury that the foregoing is true and correct.
Date: r4//) 6
U~~
M~rk E. Bennett, Agent for
Kohl's Department Store
P.O. Box 741026
Dallas, TX 75374
SC8820/1 02/08/2006 KOHL'S ACCOUNT STATUS DISPLAY 02/08/2006 14:03 ID: SAG
Aect : 0308893510 52 Cycle: 90 Bi: 02/06/2006 Due: 03/03/2006 MVC: Y VIP: N
StiLe: 90 601 CBS - DECEASED Op: 09/27/2000 Closed: 02/08/2006 Ins: N
Name1:~H L SMITH Home: 717 486 - 0019 Pull:
Name2: Bus1: 717 486 - 7613 ASer:
Addr 98 LONG STREET DR Srce: I 00000001 Emp: NScr:
R N Cis : Rstr:
CARISLE PA 170138112 AdChg: 11/18/2004 :
Instr: PRMENT DECEASED 12/20/05 PER C/B
Pymnt H: 2NMLMMLMNFPMF----------- Dun H: 210000001000000000000000
Last Stmnt Curr Stmnt Auths Last Reage:
611.82 642.99 Avl Credit:
Disputes
Last PYmnt:
Cr LInt E
Limit Ext :
MVC Pur
642.99 Issued Cards
519 01/06
697 09/00
5 01/06
Prv BaI:
Pur/Adv:
Returns:
Fee/Int:
Cr/Dr
Pymnts :
CIs Bal:
857.01
31.17
30.00 11/26/2005
1500 10% 10/06/2005
642.99
642.99
Dbt Cde: N
Cnt Sts Issue date