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IN THE IOWA DISTRICT COURT FOR SAC COUNTY SMALL CLAIMS DIVISION
L. F. NOLL, INC. 705 DOUGLAS STREET, SUITE 344 SIOUX CITY IA 51101 PLAINTIFF
VS
CARRIE HICKS FKA CARRIE AMUNRUD 612 N 5 ST SAC CITY (A 50583-1306 DEFENDANT(S)
To Defendant(s): 1. You are notified that the above-named Plaintiff demands of you the amount of $1143.98. This claim is based on the value of goods and/or services supplied by the following persons or businesses in the amounts indicated below. Said claims are assigned to Plaintiff. CREDITOR LORING HOSPITAL PRINCIPAL $1125.23 PRE-FILING INTEREST $18.75
2. Judgment may be entered against you unless you file an Appearance and Answer within 20 days of the service of the Original Notice upon you. Judgment may include the amount requested plus interest and court costs 3. You must electronically file the Appearance and Answer using the Iowa Judicial Branch Electronic Document Management System (EDMS) at https://www.iowacourts.state.ia.us/EFile. unless you obtain from the court an exemption from electronic filing requirements. 4. If your Appearance and Answer is filed within 20 days and you deny the claim, you electronic notification through EDMS of the place and time of the hearing on this matter.
receive
5. If you electronically file, EDMS will serve a copy of the Appearance and Answer on Plaintiff(s) or on the attorney(s) for Plaintiffs). The Notice of Electronic Filing will indicate if Plaintiff(s) is (are) exempt from electronic filing, and if you must mail a copy of your Appearance and Answer to Plaintiff(s). 6. You must also notify the clerk's office of any address change.
/kSSICAR. NOLLAT0008873 705 Douglas St., Ste 502 Sioux City IA 51101 Phone (712) 224-2675 Fax (712) 252-4497 jrn(5)decklaw.net ATTORNEY FOR PLAINTIFF 0002945621 JANUARY 11,2014
IN THE IOWA DISTRICT COURT FOR SAC COUNTY SMALL CLAIMS DIVISION
L F. NOLL, INC.
PLAINTIFF
VS
CARRIE HICKS FKA CARRIE AMUNRUD DEFENDANT(S) For Defendant: CARRIE HICKS FKA CARRIE AMUNRUD
1. I, T. L. Noil, Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose claim(s) is (are) shown in the attached statement(s). I have personal knowledge that the attached statement(s) is (are) a true copy of the original creditor's records showing the balance due is true and correct. I further state that the sum of $1143.98 is the balance due and owing as of JANUARY 11, 2014 from Defendant(s) to Piaintiff(s) and any interest amount owing is accurately stated in the Petition and Original Notice. 2. i further state that Defendant, CARRIE HICKS FKA CARRIE AMUNRUD. resides at 612 N 5 ST SAC CITY IA 50583-1306. is employed at CASEYS GENERAL STORE 1304 W MAIN ST SAC CITY IA 50583. and Defendant's occupation is __ . 3. Check A, B, or C for Defendant: A. X Defendant is not in the military service of the United States government, ! have verified this fact by (check one): X Checking the Defense Manpower Data Center (DMDC) (requires name and SSN or name and date of birth) https://www.dmdc.osd.mil/appi/scra/scraHome.do. a Contacting Defendant who informed me, or n Regularly seeing Defendant and believing Defendant is not active in the U.S. military. OR B. O I have investigated, and I am unable to determine whether or not Defendant is in the military service of the United States government. OR C. O Defendant is in the military service of the United States government. 4. I also state to the best of my knowledge (check one): Defendant O is X is not under a disability or confined in any reformatory, jail, or penitentiary. I certify under penalty of perjury and pursuant to the laws of the State of Iowa that these facts are true and correct. L.F. NOLL
Tfl. NOLL, VtdE PRESIDENT 705 Douglas St., Suite 344 Sioux City, IA51101 712-252-0583 0002945621
E-FILED 2014 JAN 20 2:45 PM SAC - CLERK OF DISTRICT COURT NCS, INC DBA NOLL COLLECTION SERVICE "A Professional Debt Collection Service Since 1965" 705 DOUGLAS STREET, SUITE 344 SIOUX CITY, IA 51101 (712) 252-0583
DATE: DECEMBER 11, 2013 LORING HOSPITAL ATTN JAN WISEMAN 211 HIGHLAND AVE SAC CITY IA 50583 ATTENTION: RE: CARRIE HICKS 557100 $1125.23 10/08/13 The above debtor refuses to cooperate. We recommend further action, in order to enforce collection. Before our attorney can proceed, we will require * Completion of the assignment at the bottom of this page. * Copy of the itemized statement showing balance due {if not previously provided) * If the original account is a contract or note, we must have the original. Please return promptly. Court costs will be advanced on your behalf. Do not accept payments or make arrangements, without calling us first.
THANK YOU FOR YOUR COOPERATION
014345
ASSIGNMENT FOR PURPOSES OF SUIT For valuable consideration, receipt hereby acknowledged, the undersigned hereby assign, transfer, and set over unto L.F. Noll, Inc. that certain claim against CARRIE HICKS JEREMY HICKS for goods, wares and merchandise sold and delivered or services rendered and performed in the principal amount of $1125.23 lawful interest thereon; and does hereby authorize said assignee to do and perform all acts necessary for collection; commencement of suit in the name of the assignee, settlement, adjustment, compromise or satisfaction of said claim. Assignor hereby certifies that said claim is justly due and owing and warrants compliance with requirements of the Iowa Consumer Credit Code as well as disclosure and other provisions of truth in lending, and that same is free of set-offs and other defenses. Dated this n
By:
in-VH
day of j\Lc
LORING HOSPITAL
.
(Name and Official Title)
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THIS IS AN ATTEMPT TO COLLECT A DEBT, ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE 0002943613
E-FILED 2014 JAN NCS, 20 2:45 PM DBA SAC - CLERK OF DISTRICT COURT INC NOLL COLLECTION SERVICE "A Professional Debt Collection Service Since 1965" 705 DOUGLAS STREET SUITE 344 SIOUX CITY IOWA 51101 (712) 252-0583 FAX (712) 233-3404 JANUARY 24, 2013 CARRIE AMUNRUD 612 N 5 ST SAC CITY IA 505831306
CREDITOR: LISTED BELOW IF MORE THAN ONE LORING HOSPITAL ACCOUNT NO. 0002925139 TOTAL AMOUNT DUE: $125.24 AMOUNT IN DEFAULT: $125.24 YOU ARE IN DEFAULT ON THIS CREDIT TRANSACTION. YOU HAVE A RIGHT TO CORRECT THIS DEFAULT. IF YOU DO SO, YOU MAY CONTINUE WITH THE CONTRACT AS THOUGH YOU DID NOT DEFAULT. YOUR DEFAULT CONSISTS OF: FAILURE TO PAY AS AGREED CORRECT THIS DEFAULT BY: PAYING THE AMOUNT IN DEFAULT, $125.24 TO NOLL COLLECTION SERVICE, AGENT FOR THE ABOVE CREDITOR. IF YOU DO NOT CORRECT THIS DEFAULT WITHIN 30 DAYS, WE MAY EXERCISE OUR RIGHTS AGAINST YOU UNDER THE LAW. IF YOU DEFAULT AGAIN WITHIN THE NEXT YEAR, WE MAY EXERCISE OUR RIGHTS WITHOUT SENDING YOU ANOTHER NOTICE LIKE THIS ONE. IF YOU HAVE ANY QUESTIONS, WRITE OR TELEPHONE PROMPTLY. SINCERELY,
UNLESS YOU DISPUTE THE VALIDITY OF THE DEBT OR ANY PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIPT OF THIS NOTICE, WE SHALL ASSUME THE DEBT TO BE VALID. IF YOU NOTIFY US IN WRITING OF YOUR DISPUTE WITHIN THIS 30 DAY PERIOD, WE WILL OBTAIN VERIFICATION OF THE DEBT AND WILL MAIL YOU A COPY. UPON YOUR WRITTEN REQUEST WITHIN A THIRTY DAY PERIOD WE WILL PROVIDE YOU WITH THE NAME AND AN ADDRESS OF THE ORIGINAL CREDITOR IF DIFFERENT FROM THE CURRENT CREDITOR. THIS IS AN ATTEMPT TO COLLECT A DEBT ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE CLIENT LORING HOSPITAL PRINCIPAL $123.15 INTEREST $2.09 OTHER $0.00 TOTAL $125.24
DOCTOR
GYANO , B . K . jBILLING .DATE .
E-FILED 2014 JAN 20Loring2:45 PMHospital SAC - CLERK OF DISTRICT COURT NO. TELEPHONE
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EXTENSION
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PAGE "*
712-563-6042 1 J
N.O.
INSURANCE-COMPANY 140
PATIENT NAME CARRIE AMUNRUD TYPE 11 ADMISSION DATE DISCHARGE DATE 08/22/12 08/22/12
SEX AGE 23
SAC CITY IA
//89 F
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER -THE INSURANCE COMPANIES MAKE THEIR 'PAYMENTS DATE CHARGE CODE
LEV ^ L
^^B$V&ft^^^H AMOUNT
DESCRIPTION. ~
QUANTITY
CHARGE
CPT
0 8 - 2 2 M^AA^A 0 8 - 2 2 ^^^^^^^^^^^^^
1 1
405 . 0 0 0 154.300
DEPT TOTAL
1
PROFESS
1
RADIOLOGY, TECH
135 . 0 0 0
DEPT TOTAL
SUMMARY OF CHARGES EMERGENCY ROOM RADIOLOGY, PROFESSIONAL RADIOLOGY, TECH TOTAL CHARGES
732 .97
BALANCE
*"**^-*7 * J
732.97
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E-FILED 2014 JANNCS, 20 2:45 PM DBA SAC - CLERK OF DISTRICT COURT INC NOLL COLLECTION SERVICE "A Professional Debt Collection Service Since 1965" 705 DOUGLAS STREET SUITE 344 SIOUX CITY IOWA 51101 (712) 252-0583 FAX (712) 233-3404 JUNE 14, 2013 JEREMY W HICKS CARRIE HICKS 612 N 5 ST SAC CITY IA 50583
CREDITOR: LISTED BELOW IF MORE THAN ONE LORING HOSPITAL ACCOUNT NO. 0002935004 TOTAL AMOUNT DUE: $385.02 AMOUNT IN DEFAULT: $385.02 YOU ARE IN DEFAULT ON THIS CREDIT TRANSACTION. YOU HAVE A RIGHT TO CORRECT THIS DEFAULT. IF YOU DO SO, YOU MAY CONTINUE WITH THE CONTRACT AS THOUGH YOU DID NOT DEFAULT. YOUR DEFAULT CONSISTS OF: FAILURE TO PAY AS AGREED CORRECT THIS DEFAULT BY: PAYING THE AMOUNT IN DEFAULT, $385.02 TO NOLL COLLECTION SERVICE, AGENT FOR THE ABOVE CREDITOR. IF YOU DO NOT CORRECT THIS DEFAULT WITHIN 30 DAYS, WE MAY EXERCISE OUR RIGHTS AGAINST YOU UNDER THE LAW. IF YOU DEFAULT AGAIN WITHIN THE NEXT YEAR, WE MAY EXERCISE OUR RIGHTS WITHOUT SENDING YOU ANOTHER NOTICE LIKE THIS ONE. IF YOU HAVE ANY QUESTIONS, WRITE OR TELEPHONE PROMPTLY. SINCERELY,
UNLESS YOU DISPUTE THE VALIDITY OF THE DEBT OR ANY PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIPT OF THIS NOTICE, WE SHALL ASSUME THE DEBT TO BE VALID. IF YOU NOTIFY US IN WRITING OF YOUR DISPUTE WITHIN THIS 30 DAY PERIOD, WE WILL OBTAIN VERIFICATION OF THE DEBT AND WILL MAIL YOU A COPY. UPON YOUR WRITTEN REQUEST WITHIN A THIRTY DAY PERIOD WE WILL PROVIDE YOU WITH THE NAME AND AN ADDRESS OF THE ORIGINAL CREDITOR IF DIFFERENT FROM THE CURRENT CREDITOR. THIS IS AN ATTEMPT TO COLLECT A DEBT ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE CLIENT LORING HOSPITAL PRINCIPAL $378.44 INTEREST $6.58 OTHER $0.00 TOTAL $385.02
DOCTOR
Hospital TELEPHONE E-FILED 2014 JAN 20Loring" 2:45 PM SAC - CLERK OF DISTRICT COURT NO.
EXTENSION
PAGE
211 Highland Ave Sac City, !A 50583 POLICY NUMBER POLICY HOLDER
ft
712-730-0850
MED. REC. NO. / ADMISSION NO.
33836 / PLAN
551214
INSURANCE COMPANY
XQH316AD1263 443829210
GUARANTOR
PATIENT NAME
JEREMY HICKS
612 N 5TH ST SAC CITY IA 50583
PATIENT
L4M* HICKS
TYPE ADMISSION DATE DISCHARGE DATE
33836 /
BIRTHDATE
SEX
551214
AGE
13
01/11/13
01/12/13
.*J,LJ/08 M
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS DATE CHARGE CODE DESCRIPTION QUANTITY CHARGE
CPT
AMOUNT
01-11
OBSERVATION ROOM
396. 000
396.00 396.00
711. 00 711. 00 18 .00 44 . 00 47.50 79. 00 188 .50 10. 00 10 . 00 10 . 00 10 .00 40.00 47 .63 47 . 63 95.26 135 . 00 135. 00 270 . 00 125. 00 125. 00 194 .00 291. 00 735.00
01-11
EMERGENCY ROOM
01-11 01-11 01-11 01-11
DEPT TOTAL
18 . 000 44 . 000 47 .500 39.500
LABORATORY
01-11 01-12 01-12 01-12 10 .000 10 . 000 10 . 000 10 . 000
DEPT TOTAL
PHARMACY
01-11 01-12 47. G30 47. 630
DEPT TOTAL
RADIOLOGY, PROFESS
DEPT TOTAL
135. 000 135.000
01-11 01-12 i * nn 13
RADIOLOGY, TECH
DEPT TOTAL
125 . 000 125 . 000 97. 000 97 .000
DEPT TOTAL
DOCTOR
vMARCZEWSKI, BILLING DATE 01/18/13 PAGE L. J.
TELEPHONE E-FILED 2014 JAN 20 2:45 PM SAC - CLERK OF DISTRICT COURTNO. O-^o ]\\* 2 J 21 1 Highland Ave Sac City, IA 50583 POLICY NUMBER XQH316AD1263 443829210 POLICY HOLDER HICKS, HICKS, JEREMY LOGAN
Loring Hospital
EXTENSION
NO.
I N S U R A N C E COMPANY
551214
AGE
SAC CITY IA 5 0 5 8 3
13
01/11/13
01/12/13
flT/1"
m/os M
4'
G U A R A N T O H IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE I N S U R A N C E COMPANIES MAKE THEIR PAYMENTS DATE CHARGE CODE DESCRIPTION CHARGE
CPT
SUMMARY OF CHARGES OBSERVATION ROOM EMERGENCY ROOM LABORATORY PHARMACY RADIOLOGY, PROFESSIONAL RADIOLOGY, TECH RESPIRATORY THERAPY TOTAL CHARGES
BALANCE
2435.76
y- ' '
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INC E-FILED 2014 JAN NCS, 20 2:45 PM DBA SAC - CLERK OF DISTRICT COURT NOLL COLLECTION SERVICE "A Professional Debt Collection Service Since 1965" 705 DOUGLAS STREET SUITE 344 SIOUX CITY IOWA 51101 (712) 252-0583 FAX (712) 233-3404 OCTOBER 10, 2013 CARRIE HICKS JEREMY HICKS 612 N 5 ST SAC CITY IA 50583-1306
CREDITOR: LISTED BELOW IF MORE THAN ONE LORING HOSPITAL ACCOUNT NO. 0002943613 TOTAL AMOUNT DUE: $633.72 AMOUNT IN DEFAULT: $633.72 YOU ARE IN DEFAULT ON THIS CREDIT TRANSACTION. YOU HAVE A RIGHT TO CORRECT THIS DEFAULT. IF YOU DO SO, YOU MAY CONTINUE WITH THE CONTRACT AS THOUGH YOU DID NOT DEFAULT. YOUR DEFAULT CONSISTS OF: FAILURE TO PAY AS AGREED CORRECT THIS DEFAULT BY: PAYING THE AMOUNT IN DEFAULT, $633.72 TO NOLL COLLECTION SERVICE, AGENT FOR THE ABOVE CREDITOR. IF YOU DO NOT CORRECT THIS DEFAULT WITHIN 30 DAYS, WE MAY EXERCISE OUR RIGHTS AGAINST YOU UNDER THE LAW. IF YOU DEFAULT AGAIN WITHIN THE NEXT YEAR, WE MAY EXERCISE OUR RIGHTS WITHOUT SENDING YOU ANOTHER NOTICE LIKE THIS ONE. IF YOU HAVE ANY QUESTIONS, WRITE OR TELEPHONE PROMPTLY. SINCE NOLL COLLECTION SERVICE
UNLESS YOU DISPUTE THE VALIDITY OF THE DEBT OR ANY PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIPT OF THIS NOTICE, WE SHALL ASSUME THE DEBT TO BE VALID. IF YOU NOTIFY US IN WRITING OF YOUR DISPUTE WITHIN THIS 30 DAY PERIOD, WE WILL OBTAIN VERIFICATION OF THE DEBT AND WILL MAIL YOU A COPY. UPON YOUR WRITTEN REQUEST WITHIN A THIRTY DAY PERIOD WE WILL PROVIDE YOU WITH THE NAME AND AN ADDRESS OF THE ORIGINAL CREDITOR IF DIFFERENT FROM THE CURRENT CREDITOR. THIS IS AN ATTEMPT TO COLLECT A DEBT ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE CLIENT LORING HOSPITAL PRINCIPAL $623.64 INTEREST $10.08 OTHER $0.00 TOTAL $633.72
DOCTOR
ROH, SIMON BILLING DATE 06/07/13 NO. PAGE 1 J
Loring Hospital
J\
EXTENSION
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POLICY HOLDER PROCTOR, MICHAE HICKS, CARRIE
211 Highland Ave Sac City, IA 50583 POLICY NUMBER DXM283AD9622 479769038
INSURANCE COMPANY
/
SEX
557100
AGE
TYPE
" '
11
06/01/13
06/01/13
3^0/39 F
24 Mil
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS DATE
CHARGE CODE
^gMHMBV
DESCRIPTION
UANTITY
CHARGE
06-01
06-01
^^^^^U}
405 .000
DEPT TOTAL
EMERGENCY ROOM
06-01
M^uua-r
^IliUUlfTffiE LABORATORY
18 . 0 0 0
DEPT TOTAL
06-01
REFERRAL LABORATOR
06-01 06-01
=
PHARMACY
2 2
SUMMARY OF CHARGES EMERGENCY RM PROFESSIONAL EMERGENCY ROOM LABORATORY REFERRAL LABORATORY PHARMACY TOTAL CHARGES
623". 64
BALANCE
u-
623 . 64
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Plaintiff(s), LF NOLL, INC 705 DOUGLAS ST, STE 344 SIOUX CITY IA 51101
The court file shows that the defendant has received proper notice and has failed to answer. The relief is readily ascertainable from the Original Notice. Pursuant to Iowa Code Section 631.5(6), the defendant is in default and judgment should enter accordingly. It is therefore Ordered that judgment is entered in favor of the plaintiff and against the defendant in the amount of $ 1,125.23 with interest at the rate of 2.12 % from the 20th day of January, 2014 and court costs. The Court further enters judgment for prejudgment interest in the amount of $18.75.
YOU ARE HEREBY NOTIFIED that you have a right to appeal the decision to the District Court by giving written notice to the Small Claims Office within 20 days of the filing of this order. Filing Fee for appeal is $185.00. Appeal Bond is set in the amount of: $
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State of Iowa Courts Case Number SCSC015401 Type: Case Title L.F. NOLL, INC. VS HICKS, CARRIE FKA AMUNRUD ORDER FOR JUDGMENT So Ordered
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