judgment against sac city couple in the amount $758.64

8/12/2019 Judgment against Sac City couple in the amount $758.64

1/24


2/24

INTHEIOWADISTRICTCOURT FOR SAC COUNTYSMALLCLAIM S DIVISIONL. F.NOLL,INC.70 5DOUGLAS STREET, SUITE 344SIOUX CITY IA 51101PLAINTIFF

VSANGELA SANDERS225S11THSTSACCITYIA 50583DUSTINJ.SANDERS225S11THSTSAC CITYIA50583DEFENDANT(S)

ORIGINALNOTICEANDPETITIONFORAMONEYJUDGMENT

NO.

ToDefendant(s):1. You arenotifiedthatthe abov e-nam ed Plaintiff dem ands of you the am ount of 773.82. This claim isbased on thevalueofgoodsand/orservicessupplied by thefollowingpersons orbusinessesin the amountsindicated below. Saidclaims are assigned toPlaintiff.CREDITORLOR1NG HOSPITALS1OUXLANDUROLOGY ASSOCIATESTOTAL

PRINCIPAL 733.64 25.00 758.64PRE-FILING INTEREST 14.52 .66 15.18

2. Judgmentmay beenteredagainstyou unlessyoufileanAppearanceandAnswer within 20daysof tservice of theOriginalNoticeuponyou. Judgmentmayincludethe amount requested plus interest andcoucosts3. Youmust electronically filetheAppearance an dAnswer usingthe Iowa Judicial BranchElectronicDocument Management System (EDMS) at https://www.iowacourts.state.ia.us/EFile.unless you obtain fromthe courtanexemption from electronicfiling requirements.4. IfyourAppearance and Answer isfiled within20daysand you deny theclaim, youwillreceiveelectronic notification through EDMS of the place and time of the hearing on this matter.5. If you electron ically file, EDMSwillserve a copy of the Appearance and Ans wer onPlaintiff(s)or on theattorney(s)for Plaintiff(s). The Notice ofElectronicFilingwillindicate ifPlaintiff(s)is(are) exempt fromelectronic filing, and if you mustmailacopyof your Appe arance and Ans wer toPlaintiff(s).6. You must also notify the clerk'soffice of any address change.

E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT


3/24

/O fSS ICAR. NOLLAT0008873)5DouglasSt.,Ste 5 2Sioux City IA51101Phone 712) 224-2675Fax 712)[email protected] FO RPLAINTIFF0002837481MAY6,2014



4/24

IN THE IOWA D ISTRICT COURT FOR SAC COUNTYSMALL CLAIMS D IVISION

L.F.NOLL INC.PLAINTIFF

ANGELASANDERSDUSTIN J. SANDERSDEFENDANT(S)

VERIFICATION OFACCOUNTIDENTIFICATION OFJUDGMENTDEBTORAND CERTIFICATE RE

MILITARYSERVICENO

ForDefendant : A N G E L A S A N D E R S

1. I, T. L.Noll, Vice President of L. F. Noll, Inc., am aparty or employee of Plaintiff whoseclaim(s) is(are)shownin the attached statement(s). Ihave personal knowledge thattheattached statement(s) is (are)atruecopyof the original creditor's records showing thebalancedue istrue and correct. I further state that the sumof 773.82 is the balance due and owing as of MAY 6,2014 from Defendant(s) toPlaintiff s) and any interestamount owing is accurately statedin the Petition andOriginal Notice.2. I furtherstate that Defendant, ANGELA SANDERS, resides at 225 S 11TH STS ACCITY IA 50583. isemployed at , and Defendant soccupation is .3. Check A, B, or C for De fendant:

A. X Defendant is not in the military serviceof the United States government, Ihave verified this faby(check one):X Checkingthe Defense Manpower Data Center (DMDC) (requires nameand SSN or nameand date of birth) https://www.dmdc.osd.mil/appi/scra/scraHome.d_o.n Contacting Defendantwho informed me, orn Regularly seeing Defendant and believing Defendant is notactivein the U.S. military.OR B. O Ihaveinvestigated,and I amunable todetermine whether or not Defendant is in the militaryservice of the United States government.OR C. O Defendant isin the military serviceof the United States government.4. Ialsostateto the bestof myknowledge (check one):Defendant O is X isnotunder a disability orconfined in anyreformatory,jail, or penitentiary.I certify under penaltyofperjuryand pursuant to the lawsof the Stateof Iowa that these facts aretrue andcorrect.

LF. NOLL, INC.

T.JXNOLL, VfCE PRESIDENT705 Douglas St., Suite 344SiouxCity, 1A51101712-252-0583

283748



5/24

NOTICEOFRIGHTTOCUREDEFAULTHCS, INC DBANO.LLCOLLECTION"SERVICE705 DOUGLAS STREET, SUITE 344PO.BOX593SIO U X , CITY IA 51102-0593712)252-0583APRIL 10, 2014ANGELA SANDERSDOSTINSANDERS225 S 13.THSTSACCITYIA50583

[LISTEDBELOWIFMORET.H.AN ONE) TOTALAMOUNTDUE:$773.82 . . v: : > .AMOUNT IN DEFAULT:$733.64You .are.nowindefault onthis credit transaction.; ouhavearightto. . ; .

correctthis default within 20days. If you doso,y.ou, may continuewith. che.contractasthoughyou did not default... . . , . . ; . . . . ... _ . . _ .YOUR.DEFAULT CONSISTSOF:Correctthisdefaultby:

FAILURE T O -PAY ASAGREED . ,Paying theamountindefault,$733.4 to NollCollectionService,agent for theabo.vecreditor.

; , If y ou do notcorrect this default-within 20days')-wemay exercise" bur-rightsagainst y o u under t h e law.. - - - T . - .Ifyou default: again in the next year,wemayexerciseourrights.without'.

sending you another notice like thisone.- \ f y o uhaye-.any.ques.ti.ons,-write:.ortelephone,promptly.Sincerjely,

L. F i Noll

THIS IS ANATTEMPTTOCOLLECT ADEBT, . . .:... : ANYAND ALLINFORMATION OBTAINED>IILL BEUSED FORTHAT PURPOSE ;000283^481-ClientName Client Ref No Principal Interest .Other Tota'i

L O R I N G H O S P I T A L 4 7 4 11 8L O R I N G H O S P I T A L 5 3 3 1 S-5 .LORING;HOSPITAL 537128S X O U X L A N D U R O L O 0 0 4 1 9 2 3 9253 27330 37iso.oa25.00

f f 2 8 .5 . 8'4 - : '2 ^ 4 .,.66: ,

0000

259,55336 21152-.4 o ,25-66.773 82



6/24

NCS,INC DBANOLLCOLLECTION SERVICE

AProfessional DebtCollectionService Since 1965 -705 DOUGLAS STREET, SUITE 344

SIOUX CITY,ilA51101(712)252-0583

DATE: APRIL 9, 2014LORINGHOSPITAL 014345ATTN JA N WISEMAN211 HIGHLAND AVESACCITYIA50583ATTENTION:RE:DUSTIN J SANDERS

474118 $733.64 12/29/08Theabove debtor refusestocooperate.Werecommend further action,in

ordertoenforcecollection. Beforeourattorneycanproceed,wewill require*Completionof theassignmentat thebottomofthis page.*Copy of theitemized statement showing balancedue [if notpreviouslyprovided)

* If theoriginal accountis acontractornote,wemust havetheoriginal.

Please return promptly. Court costs-willbeadvancedonyour behalf.Donotaccept paymentsormake arrangements, without callingusfirst.

THANKYOU FORYOUR COOPERATION

ASSIGNMENT FORPURPOSESOFSUIT Forvaluable consideration,'receipt hereby acknowledged,theundersigned herebyassign,transfer,and setoveruntoL.F. Noll, Inc. that certain claim against

DUSTINJ SANDERSANGELA SANDERSforgoods, waresandmerchandise soldanddeliveredorservices renderedand

performedin the principalamountof $733.64 lawful interestthereon;and does hereby authorize said assignee to do and perform all actsnecessaryforcollection; commencementofsuitin thenameof theassignee,settlement,adjustment,compromise orsatisfactionof said claim. Assignorhereby certifies thatsaid claimisjustlydue andowingandwarrantscompliance with requirementsof theIowa Consumer Credit Codeaswellasdisclosure and other provisions of truth in lending, and that same isfreeof'set-offsandotherdefenses.DatedthisLORING HOSPITAL

Q i M j J iA a t f x 4 ut a m e and fficial TitleTHIS.ISA NATTEMPT TOCOLLECTADEBT,

ANY INFORMATIONOBTAINEO JWILLBE USED FOR THATPURPOSE'0002802519



7/24

D O C T O RPEK Z. L.

BILLING DATE03 05 12 PAGE

Lorin^H ospital TELEPHONE N O

21 1 Highland Ave Sac Ci ty, A 50583

712-299-2938EXTENSION

MED, R E C .NO. /A D M I S S IO N NO .30756 537128

NO I N S U R A N C E C O M P A N Y POLICY NUMBER POLICY H O L D E R PLAN 7 5

BLUE CROSS 140SELF-PAY

XQH331AD8081480158326

SANDERS DTJSTINSANDERS DUSTIN

G U A R A N T O R PATIENT NAME MED REC NO / DMISS ION NODUSTINSANDERS

225S THSTREETSACCITYIA 50583

DUSTIN SANDERS 30756/ 537128PATIENT

13ADMISSION D A T E02 28 12

D I S H R G E DATE02 28 12

B I R T H D A T E

G U A R A N T O R I S R E S P O N S I BL E F O R A N Y A M O U N T S D U E A FT E R T H E IN S U R A N C E C O M P A N I E S M A K E T H E IR P A Y M E N T S D A T E C H A R G EC O D E D E S C R I P T I O N QUANTITY C H A R G E C P T

SEXM

A G E28

P Y L STB L NCEAMOUNT

02 28

02 28

2 28 2 28 2 28 2 28

2 28 2 28 2 28 2 28

2 28 2 28 2 28 2 28

02-2802-28

02-28

02-28

02-28

OBSERVATION ROOM

EMERGENCY ROOM

INFUSION/CHEMOTHE

LABORATORY

PHARMACY

RADIOLOGY PROFESS

RADIOLOGY TECH

ULTRASOUND

IVSOLUTIONS

308.000

711.000

63.00072. 00020400067.000

12.00017.72044.00047.500

87.83087.83096.7108000

40.480130.300

135 . 000

294000

13.060

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

308.00308.00

711.00711.00276.0072.00204.0067.00619.0012 . 0017.7244 .0047 .50121.22

87 .8387 .8396 7116 00288.37

40 .48130.30170.78135.00135 .00

294.00294.0013.0613 .06



8/24

D O C T O RPER 2. L.

BILLING DATE03/0 6/12 PAGE

Lor ing-Hospital

2 11 H ighland Ave Sa c City, A 50583

TELEPHONE NO .712 299 2938

EXTENSION

MED REG.NO. /ADMISSIONNO .30756 537128

NO INSURANCE C O M P A NY POLICY HOLDER PLAN0705

BLUE CROSS 140SELF-PAY

XQH331AD808148015892S

SANDERS DUSTINSANDERS DUSTIN

G U A R A N T O R PATIENT NAME MED REC.NO / D MISSION NODUSTIN SANDERS

225S11THSTREETSACCITY IA 50583

DUSTIN SANDERS 3075S/ 537128PATIENTTYPE

13A D M I S S I O N D A T E02 28 12

D I S C H A R G E D A T E02 28 12

BIRTH D AT E S EXM

AG E 8

GUARANTOR. IS RESPONSIBLEF O R A NY A M O U N T S D UE AFTER T H E INSURANCE CO MPANIES MAKE THEIR PAYMENTSDA TE C H A R G EC O D E DESCRIPTION QUANTITY CH A RGE CPT

P Y L STB L NCEAMOUNT

SUMMARYOPCHARGESOBSERVATION ROOMEMERGENCY ROOMINFUSION/CHEMOTHERAPYLABORATORYPHARMACYRADIOLOGY PROFESSIONALRADIOLOGY TECHULTRASOUNDIV SOLUTIONS

TOTAL CHARGES

BALANCE

308 . 00711.00619.00121.22288.37170 .78135.00294.0013.06

2660.43

2650 43



9/24


10/24

1D O C T O R

PEK Z. L.BILLING DATE12/07/11 PAGE 1

NO.05

~ Loring-Hospital ^oypyv?f

27 1 HighlandAve Sac City IA 50583I NSU RANCE CO M PANY

SELF-PAYPOLICY NUMBER

611033380

G U A R A N T O RANGELA SANDERS225 S11THSTSAC CITY IA 50583

TELEPHONE NO . EXTENSION712-662-4008MED. REC.NO. / ADMISSION NO.33093

POLICYHOLDERSANDERS QUINTE

PATIENTNAME_SANDERSPATIENTTYPE11

A DM I S S I ON DATE11/2611 D I S C H A R G ED A T E11/2611

PLAN/ 533164

MED. REC.NO. / ADMISSION NO.33093 / 533164

BIRTHDATE SEX AGEW/08M 2GU A RA NT OR I S RESPONSIBLEFO R A NY A M O U N T S D UE AFTER THE INSURANCE C O M PANIES MAKE THEIR PAYMENTS

D A T E11-2611 26

C H A R G EC O D E DESCRIPTION4MMc*-EMERGENCYPHARMACY

SUMMARYEMERGENCYPHARMACY

R O O MOF CHARGESROOM

TOTAL CHARGES

BALANCE

QUANTITY11

CHARGE308.00

22 .37

308.0022 .37

330.37

C PT

DEPT TOTAL

DEPT TOTAL

PAYLASTBALANCEA M O U N T

308.00308.00

22.3722.37

330 .37



11/24

NCS, INC DBANOLL COLLECTION SERVICE

AProfessionalDebtCollectionServiceSince19SS705DOUGLAS STREET, SUITE344

SIOUX CITY, IA 51101(712)252-0583

DATE: APRIL 9,2014SIOUXLANDUROLOGY ASSOCIATES 025500P0 BOX2020NORTHSIOUX CITY SD 570492020ATTENTION:RE:DUSTIN JSANDERS

00419239 25.00 09/14/12The above debtor refuses to cooperate. We recommend further action, in

order to enforce collection. Before our attorney can proceed, we will require.*Completionof theassignmentat thebottomofthis page.*Copy of,theitemized statement showing balancedue {ifnotpreviously provided)

* If the original account is a contract or note, we must have theoriginal.

Please return promptly. Court costs will be advanced onyourbehalf.Donot accept payments or makearrangements,without calling us first.


ASSIGNMENTFORPURPOSESOFSUITForvaluableconsideration, receipt hereby acknowledged, the undersignedherebyassign, transfer, and set over unto L.F. Noll, Inc. that certain claim against

DUSTINJSANDERSANGELA SANDERSforgoods, wares and merchandise sold and delivered or services rendered and

performed in the principal amount of $25.00 plus lawful interestthereon; and does hereby authorize said assignee to do and perform all actsnecessary for collection; commencement of suit in the name of theassignee,settlement, adjustment, compromise or satisfaction of said claim. Assignorhereby certifiesthatsaid claim is justly due and owing and warrantscompliance with requirementsof theIowa Consumer Credit Codeaswellasdisclosureand otherprovisionsoftruthinlending,andthat sameis free ofset-offs andother defenses.

? - 7da y o f=4>3>\ [ /atedthis : day of_ /iA , 20 /SIOUXLAND UROLOGY ASSOG'IATESX

/ 1x7By:U L{NameandOfficial TitleT--

THISISCftNATTEMPTTOCOLLECTADEBT, INFORMATION OBTAINED WILLBEUSEDFORTHAT PURPOSE.

000291S871



12/24

Account LedgerUrologyAssociates Box2020Dunes,SD 57049

(605)217-7010

5S 11th StcCity,IA 50583

Tax ID;420982360 Account: 00419239Responsible Party: SelfInsurance1 (XQH331AD8081)BCBSIowaWellmark

Phone:(712) 662-4008Phone:

PrimaryProvider: (9)TimothyKneibReferringPhysician: 689)Zoitan P ek

Patient,BalanceMInsurance Pending

Provider U I

Status Service Date Code Description Charge Payment Ad (9)KneibI (9)KneribA (9) KneibA (9)KneibM MemoM MemoEntry Date: 03/09/2012

Bill , 03/29/2012,03/29/20123 - tO>BeBSrlowabWellmark ^ t' ' J i * IHM' i , 0034108599 1Bill Q3/2Ql2fy\2 03/29/2012CO45J ' - 0.Charges^xceedcontracted fee

Bill 09/17/2012 09/1,7/2012cj., 0'CoIlebtibnWnteOff03/09/2012 Ins Code sequence onvisit[3];by user:DBertrand03/29/2012 $25.00appliedtoco-paymentVisitBalance: $0.00 $188.00

,r($135.00) ($2

1 ($($135.00) ($5

=Charge;I =Insurance Payment;P =Private Payment;A =Adjustment;F=Insurance Filing;M =MemoAllVisitspreliminary(open)transaction thatissubjecttoreview.

2:26:47P M Created by: VJauer ID:17 Ver 1.15.2.9 Page



13/24

IN THE IOWADISTRICTCOURTFOR SAC COUNTYSMALL CLAIMS DIVISIONL. F. NO LL INCPLAINTIFF

VSANGELA SANDERSDU STI N J .SANDERSDEFENDANT(S)

VERIFICATIONO ACCOUNTI DE N T I F I CAT I ON OFJUDGMENTDEBTORA N D CERTIFICATEREMILITARY SERVICE

NO.ForDefendant: DUSTINJ .SANDERS

1. I, T. L.Noll, Vice Presidentof L. F. Noli, Inc., am apartyoremployeeo fPlaintiff whoseclaim(s) is(are)shownin theattached statement(s). Ihave personal knowledge thattheattached staternent(s)is(are)atruecopyof theoriginal creditor s records showingthebalancedue istrueandcorrect. Ifurther state thatthe sumof 773*82is the balance due andowing as of MAY 6,2014 fromDefendant(s)to Plaintiff(s) and any interestamount owing isaccurately statedin thePetition and Original Notice.2. Ifurther state that Defendant,DUSTINJ.SANDERS, residesat 225 S11THST SACCITY IA50583.isemployedatPU\NTINUMETHANOL2585 QUAILAVEARTHURIA51431.andDefendant's occupationis

3. CheckA, B, or C for Defendant:A. X Defendantis not in themilitaryserviceof theUnited States government,Ihaveverifiedthis factby(checkone):X CheckingtheDefense Manpower Data Center (DMDC) (requires name and SSN orname

anddateofbirth)https://www.dmdc.osd.miI/appi/scra/scraHome.do.D Contacting Defendantw ho informedme, orn Regularly seeing Defendant andbelieving Defendantis notactivein theU.S. military.OR B. 0 Ihave investigated, an d am unableto determine whether or notDefendantis in the militaryserviceof theUnited States government.OR C. O Defendant is in the militaryserviceof the United States government.4. Ialso stateto thebestof my knowledge (check one):Defendant O is X is not underadisability orconfinedin any reformatory,jail,or penitentiary. certify under penalty ofperjuryan dpursuantto the lawsof the StateofIowa that these factsaretrue andcorrect.

L.F. NOLL,IN

T. NOCL,Vf E PRESIDENT705Douglas St., Suite344Sioux City,IA51101712-252-0583

283748



14/24

NOTICEOFRIGHTTOCUREDEFAULTNCS, INC DBANOLLCOLLECTIONSERVICE705DOUGLAS STREET, SUITE344POBOX 593SIOUX CITYIA51102-0593{712)252-0583APRIL 10,2014ANGELASANDERSDUSTIN SANDERS225 S11THSTSACCITY IA50583

RE: (LISTEDBELOW IF MORE THAN ONE)TOTAL AMOUNTDUE: 773.82AMOUNTIN DEFAULT: 733.64Youare now In default on this credittransaction.. Youhavea right to

correct this defaultwithin20 days. If you do so, y.ou. may continue withthecontractas though you did not default.YOURDEFAULT CONSISTSOF:Correct this defaultby:

FAILURE TO PAY AS AGREEDPaying the amount indefault, 733.64 toNoll Collection Service, agent for the abovecreditor.

. If you do notcorrect this default within20days;- we mayexercise1 ourrights againstyouunderthelaw.

If you default again in the next year,w may exercise our rights withoutsending you another noticelikethisone.-.-Ifyouhave:-anyquestions, write,ortelephonepromptly.Sincerely,

L. F.Noll

THISIS AN ATTEMPT TO COLLECT A DEBT,ANYAND ALL INFORMATIONOBTAINEDWILL BE USED FORTHATPURPOSE.0002837481-ClientName Client Ref No Principal Interest Other TotalLORING HOSPITALLORING HOSPITALLORING HOSPITALSIOUXLANDUROLO

47411853316453712800419239

253,330,150.25.

.27,37,00.00

6.5 .2.

2 8 8 4 - 406 6 . .

.00

.00,00.00

259.336.152,25,

,55,21 '.40..66.

773.82



15/24

NCS,INC DBANOLL COLLECTION SERVICE

AProfessional Debt Collection Service Since1965 705DOUGLASSTREET, SUITE 344

SIOUX CITY,ilA51101(712) 252-0583

DATE: APRIL9,2014LORINGHOSPITAL 014345ATTN JAN WISEMAN211 HIGHLAND AVESACCITYIA50583ATTENTION:RE:DUSTIN J SANDERS

474118 $733.64 12/29/08Theabove debtor refusestocooperate.Werecommend further action,in

ordertoenforcecollection. Beforeourattorneycanproceed,wewillrequire* Completion of theassignment at thebottomofthis page.*Copyof theitemized statement showing balancedue (if notpreviously provided)

*If theoriginal accountis acontractornote,wemust havetheoriginal.Please return promptly. Courtcosts*willbeadvancedonyour behalf.

Donotaccept paymentsormakearrangements,without callingusfirst.THANKYOU FORYOUR COOPERATION

ASSIGNMENT FORPURPOSESOFSUIT Forvaluable consideration,'receipt hereby acknowledged,theundersigned herebyassign,transfer, and setover unto L.F. Noll, Inc. that certain claim against

DUSTIN J SANDERSANGELASANDERS .

forgoods, waresandmerchandise soldanddeliveredorservices renderedandperformed in the principal amount of $733.64 lawful interestthereon;anddoes hereby authorize said assigneeto do andperformallactsnecessaryfor collection; commencement of suit in the name of the assignee,settlement, adjustment, compromise or satisfaction of said claim. Assignorherebycertifies that said claimisjustlydue andowingandwarrantscompliance with requirementsof theIowa Consumer Credit Codeaswellasdisclosure andother provisions oftruthinlending, andthat sameisfreeof 'set-offsandother defenses.Datedthisf4 dayo ft_ 2LORINGHOSPITAL

^NameandOfficial Title) THIS.IS_ANATTEMPT TOCOLLECT ADEBT,

ANY INFORMATION OBTAINED'-JWILLBEUSEDFORTHATPURPOSE .0002802519



16/24

DOCTORPEK Z. L.

BILLING DATE03 06 12 PAGE

orin Hospital TELEPHONE W O.

21 1Highland Ave Sac City, A 5 583

712-299-2998EXTENSION

MED. REG.MO. /ADMISSIONNO.30756 537128

NO INSURANCE COMPANY POLICY NUMBER PO LICYHOLDER PLAN0705

BLUE CROSS140SELF-PAY

XQH331AD3081480158926

SANDERS DUSTINSANDERS DUSTIN

G UARANT OR PATIENT NAME MED REC.NO /DMISSIONNODUSTINSANDERS

225S11THSTREETSACCITYIA 50583

DUSTINSANDERS 30756/ 537128PATIENTTYPE

ADMISSION DATE 2 28 12

DISCHARGE DATE 2 28 12

BIRTHDATE

GUARANTOR IS RESPONSIBLE FOR ANY AM OUNT S DUE AFTER THE INSURANCE COMPANIES MAK E THEIR PAYMENTSDATE CHARGECODE DESCRIPTION QUANTITY CHARGE CR T

S EX

AGE28

P YL ST L NCEAMOUNT

02 28

02 28

02 2802 2802 2802 28

02 2802 2802 2802 28

02-2802-2802-2802-28

02-2802-28

02-28

02-28

02 28

OBSERVATION ROOM

EMERGENCY ROOM

INFUSION/CHEMOTHE

LABORATORY

PHARMACY

RADIOLOGY PROFESS

RADIOLOGY TECH

ULTRASOUND

IVSOLUTIONS

1 308 . 000

711.000

69.00072. 000204.00067. 000

12.00017.72044. 00047.500

87. 83087 83096.7108. 000

40.480130.300:

135.000

294.000

13.060

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPTTOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

308.00308.00

711.00711.00276.0072. 00204.0067.00619.00

12.0017.7244. 0047.50121.22

87.8387. 8396.7116.00288 .37

40.48130 .30170.78135.00135.00

294 .00294.0013. 0613. 06



17/24

J D O T O R Lor ing HospitalPEK, Z. L. -%-

B I L L I N G D A T E j\03/0.6/12 PAGE 2 J 211HighlandAve Sa c City 1A50583

T E L E P H O N E N O . EX TEN S I O N712-299-2998M E D . R E C . N O . / A D M I S S I O N N O .30756 / 537128

N O . I N S U R A N C E C O M P A N Y P O L I C Y N U M B E R P O L I C Y H O L D E R P L A N07 BLUE CROSS 140 XQH331AD8081 SANDERS, DUSTINO S SELF-PAY 480158926 SANDERS, DUSTIN

G U A R A N T O R P A T I E N T N A M E M E D . R E C . N O . / A D M I S S I O N N O .DUSTIN SANDERS DUSTIN SANDERS 30756 / 537128225 S 11TH STREET ^TYp A D M I SS IO N D A T E D I S C H A R G EDATE B I R T H D A T E SEX AGESAC CITY IA 50583 13 02/28/12 02/28/12 /83M 28

G U A R A N T O R .ISR E S P O N SI B L E F O R A N Y A M O U N T S D U E A FT E R T H E I N S UR A N C E C O M P A N I E S M A K E T H E I R P A Y M E N T SD A T E

:

C H A R G EC O D E

5'i//3-e f t

D E S C R I P T I O NSUMMARY OF CHARGES

OBSERVATION R O O MEMERGENCY R O O MINFUSION/CHEMO THERAPYLABORATORYPHARMACYRADIOLOGY, PROFESSIONALRADIOLOGY, TECHULTRASOUNDIV SOLUTIONSTOTAL CHARGES

BALANCE

/S\>^>-^ o ^ I ) 3

Q U A N T I T Y

C H A R G E

308.00711.00619.00121.22288.37170. 78135.00294.0013 .06

2660.43

-

CPT

\i \a^A/) y- r\p-4eP

< f A

PAYLASTBALANCEA M O U N T

2660.43


18/24

D O C T O R . Loring-Hospital ^ ^ C ^ P H O N ^ N C ^ - ^ E X T E N S I O N ^MARCZEWSKI, L. J.

B I L L I N G DATE ' ^c/br06/20/08 PAGE 1 J 211 Highland Ave-SacCity,IA 5 583

712-299-2998^ M E D ^ REC^N O .7 :& b M iS S IO N ' 'N O ;^

30756 /474118N O I N S U R A N C E .C O M P A N Y -, , P Q U C Y . N U M B E R ; P O L I C Y H O L D E R P L A N07 BLUE CROSS 140 NTI271AD508505 SELF-PAY ,,480158926/i X /^7 $ ~ ~ G U A R A N T O R / *" >DUSTIN SANDERS

225 S11THSTSAC CITY IA 50583

SANDERS, DUSTINSANDERS DUSTIN

PATIEN T N AME rr. > > MED REC NO / A D M I S S I O N N O

- P A T I E N T ^r'.'tTYPE*-?' -11

DUSTIN SANDERS 30756 /474118ADMl^jpNlBATE. D'lSCHA'ftGE'. 'DATE- .: B I R T HDATE- ;:' -S, - /AGE?-i,;/':\05/22/08 05/22/08 4083M 25

G U A R A N T O R - I S - R E S P O W S I B L E F O R AN Y A M O U N T S DUE'AFTER TH E I N S U R A N C E C O M P A N I E S M A K E T H EI R P A Y M E N T S; ' - D A T E ) :05-22

05-2205-2205-22

05-22

' - . ' C H A R G E. ' C O D E -

40HHH*a0M

DESC R I PTI ON

E M E R G E N C Y R O O M

LABORATORY

MEDICAL SUPPLIES

S U M M A R Y OF CHARGESEMERGENCY R O O MLABORATORYMEDICAL SUPPLIESTOTAL CHARGES

BALANCE

* *> Q U A N T I T Y111111

. C H A R G E231.000

12.00012.56044.00047.500

1.800

231.00116.06

1.80

348'. 86

CP T

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

->9.-C&15c0.ft

PAY LASTBALANCEA M O U N T

231.00231.00

12.0012.5644.0047.50

116.06

1.801.80

348'.86



19/24

v DOCTORPEK Z. L.

BILLING DATE12/07/11 PAGE 1

NO.05

LorinfHospital ^Q^*

ft A1v?f211HighlandAve Sac City IA5 583INSURANCECOMPANY

SELF -PA YPOLICY NUMBER

611033380

G U A R A N T O RANGELA SANDERS225 S11THSTSAC CITY IA 50583

TELEPHONE NO. EXTENSION712-662-4008MED.REC. NO. /ADMISSION NO.33093

POLICYHOLDERSANDERS QUINTE

PATIENT NAMEMSANDERSPATIENTTY P E ADMISSION DATE1126/11 DISCHARGE DATE1126/11

FLAN/ 533164

MED. REC.NO. /ADMISSIONNO.33093 / 533164

BIRTHDATE SEX AGE9 QB M 2

GUARANTOR ISRESPONSIBLEF OR ANY AMOUNTS DUEAFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTSDATE

11-26

11-26

CHARGECODEOTMMMV

DESCRIPTIONJBMMIfc-EMERGENCYVMMMWPHARMACY

SUMMARYEMERGENCYPHARMACY

ROOMOP

i HHh.

CHARGESROOM

TOTAL CHARGES

BALANCE

QUANTITY CHARGE308.00022.370

308 .0022.37

330.37

CPT

DEPT TOTAL

DEPT TOTAL

PAYLASTBALANCEAMOUNT

308.00308.00

22.3722.37

330.37



20/24

NCS,INC DBANOLLCOLLECTION SERVICE

AProfessional Debt Collection Service Since1965"705DOUGLAS STREET, SUITE344

SIOUX CITY, IA51101(712)2S2-0583

DATE: APRIL9,2014

SIOUXLANDUROLOGY ASSOCIATES 025500PO BOX2020NORTH SIOUX CITY SD 570492020ATTENTION:RE:DUSTINJ SANDERS

00419239 $25.00 09/14/12The above debtor refuses to cooperate. We recommend further action, in

order to enforce collection. Before our attorney can proceed, we will require*Completionof theassignmentat thebottomofthis page.*Copy of.theitemized statement showing balancedue (if notpreviously provided)

* If theoriginal accountis acontractornote,wemust havetheoriginal.

Pleasereturnpromptly. Court costs will be advanced on your behalf.Do not accept payments or makearrangements,without calling us first.


ASSIGNMENTFORPURPOSESOFSUITFor valuable consideration, receipt hereby acknowledged, the undersigned herebyassign, transfer, and set over untoL.F.Noll, Inc. that certain claim against

DUSTINJSANDERSANGELA SANDERSforgoods, wares and merchandise sold and delivered or services rendered and

performed in the principal amount of$25.00 plus lawful interestthereon;anddoes hereby authorize said assigneeto do andperformallactsnecessaryforcollection; commencementofsuitin thenameof the assignee,settlement, adjustment, compromise or satisfaction of said claim. Assignorhereby certifies thatsaidclaim is justly due and owing and warrantscompliance with requirements of the Iowa Consumer Credit Code as well asdisclosureandother provisionsoftruthinlending,andthatsameisfreeofset-offs"andother defenses.Datedthis day of^jtn j i i ~ ,20_/_4SIOUXLAND UROLOGYASSOG

f >(Name andOfficialTitleJ

U/~THISIS


21/24

Account LedgerUrologyAssociatesBox 2020Dunes,SD 57049

(605)217-7010

5S11thStcCity, IA 50583

TaxID:420982360 Account: 00419239Responsible Party: SelfInsurance (XQH331AD8081)BOBS Iowa Wellmark

Phone:(712) 662-4008Phone: Referring Physician: (689)ZoltanPek

Provider^Bill

Status ServiceDate Code Description Charge Payment Ad9)Kneib

9) KneibA {9)KneibA (9)KneibM MemoMMemo

Bill l l

Bill

-03/06/201203/06/2012*03/29/201203/29/2012-3 $18800

l l~ ~ 03/09/201203/29/2012

ow aWellmark 00341085990 Charges,,exceed contracted fee^schedule t j ,

, 0CollectionWriteOff; __InsCodesequence onvisit [3];by user:DBertrand$25.00applied to co-payment.

($13500)03/29/203203/29/2012CO45.' i i09/17/201209/17/2012 C

($2($2

Date: 03/09/2012 VisitBalance: 0.00 188.00 ($135.00) ($5

iifc p p;. ?:1=Charge; I=Insurance Payment;P=Private Payment;A =Adjustment; F =InsuranceFiling;M =MemoAllVisitsa preliminary (open) transactionthatis subject to review.

2:26:47PM Created by:VJauer ID: 17 Ve r1.15.2.9 Page



22/24

E-FILED 2014 MAY 23 10:44 AM SAC - CLERK OF DISTRICT COURT


23/24

IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

Plaintiff(s), SMALL CLAIMS DIVISIONL F NOLL INCPO BOX 593SIOUX CITY IA 51102

Case: 02811 SCSC015434

vs.

JUDGMENT ENTRYDefendant(s),

ANGELA R BARAIBAR225 S 11TH STSAC CITY IA 50583

DUSTIN J SANDERS225 S 11TH STSAC CITY IA 50583-0

The court file shows that the defendants have received proper notice and have failed to answer. Therelief is readily ascertainable from the Original Notice. Pursuant to Iowa Code Section 631.5(6), thedefendant 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(s), in the amount of $758.64 with interest at the rate of 2.11% from the 12th day of May ,2014 andcourt costs.The Court further enters judgment for prejudgment interest in the amount of $15.18.

YOU ARE HEREBY NOTIFIED that you have a right to appeal the decision to the District Court bygiving written notice to the Small Claims Office within 20 days of the filing of this order. Filing Fee forappeal is $185.00. Appeal Bond is set in the amount of: $600.00

1 of 2

E-FILED 2014 JUN 06 12:48 PM SAC - CLERK OF DISTRICT COURT


24/24

State of Iowa Courts

Case Number Case TitleSCSC015434 L F NOLL INC VS SANDERS ANGELA AND DUSTIN JType: ORDER FOR JUDGMENT

So Ordered

Electronically signed on 2014-06-06 12:48:41

E-FILED 2014 JUN 06 12:48 PM SAC - CLERK OF DISTRICT COURT

judgment against sac city couple in the amount $758.64

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