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7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
1/15
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
2/15
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
SHERRY L.
BAILEY
31 7
LEONARD
ST
SA C
CITY IA 50583
DEFENDANT S)
ORIGINAL NOTICE AND PETITION
FOR A MONEY JUDGMENT
NO.
To Defendant(s):
1. You are notified that the above-named Plaintiff demands o f you the amount of 804.57. Thisclaim is
based on the value of goods and/or services supplied by the following persons or businesses in the amou nts
indicated below. Said claims are assigned to Plaintiff.
CREDITOR
LORING HOSPITAL
PRINCIPAL
789.93
PRE-FILING
INTEREST
14.64
2
Judgm ent may be entered
against
you unlessyo u
file
an
Appearance
an d
Answ er within
20 daysof the
service
of the O riginal No tice upon you. Judgment may include the amount requested plus interest and court
costs.
3.
You m ust electronically file the Appearance and Answer using the Iowa Judicial Branch Electronic
Document Management System (EDMS) at https://www.iowacourts.state.ia.us/EFile.unlessyou obtain from
the
court an exem ption from electronic filing requirements.
4. Ifyour Appearance
and
Answer
is
filed within
20
days
and you
deny
the
claim,
yo u
will receive
electronicnotificationthroughEDMS of the placeandtimeof thehearingonthis matter
5.
If you
electronically file, EDMS will serve
a
copy
of the
Appearance
and
Answer
on
Plaintiff(s)
or on the
attorney(s)
fo r
Plaintiff(s).
The
Notice
o f
Electronic Filing will indicate
if
Plaintiff(s)
is
(are) exempt from
electronic filing,
and if you
m ust mail
a
copy
of
your Appearance
and
Answer
to Plaintiff(s).
6 You
must also notify
the
clerk's office
of any
address change.
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
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R.NOLLAT0008873
705
Douglas
St. Ste 502
SiouxCityIA51101
Phone 712)224-2675
Fax
712) 252-4497
irn@decklaw.net
ATTORNEY FOR PLAINTIFF
956733
OCTOBER
30,
2014
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
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IN T HE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLA IMS DIVISION
L. F.
NOLL INC.
PLAINTIFF
VS
SHERRY L. BAILEY
DEFENDANT(S)
VERIFICATION O F ACCO UNT
IDENTIFICATION OFJUDGMENT
DEBTOR
AN D
CERTIF ICATE
R E
MILITARY SER VICE
NO
For Defendant: SHERRY L. BAILEY
1. I, T. L. Noll, Vice President of L. F.Noll Inc., am a partyorem ployee 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
th e
balance
due is
true
and
correct.
I
further state that
the sum
of 804.57 is the balance due and owing as of OCTO BER 30, 2014 from Defendan t(s) to Plaintif f (s) and any
interest amount owing is accurately stated in the Petition and Original Notice.
2. I further statethat Defendant, SHERRY L.BAILEY,
resides
at 31 7LEONARD ST SAC
CITY
IA
50583.
is
employed
at
LQRING HOSPITAL
21 1HIGHLAND AVE 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 S tates governm ent, I have verified this fac
by (check one):
X Checking the Defense Manpow er Data Center (DMDC) (requires name and SSN or name
and
date
of
birth) https://www.dm dc.osd.mil/appi/scra/scraHom e.do.
-
Conta cting Defendant
who
inform ed
me or
. Regularly seeing Defendant and believing De fendant is not active in the U.S.
mil i tary.
OR
B. O I
have
investigated and I amunabletodetermine
whether
or notDefendantis in themilitary
OR
service of the United States governm ent.
C.
O Defendant
is
in the military service of the United States government.
4. I also state to the best of m y knowledge (check one):
Defendant
O is X is no t
under
a
disa bility
or
confined
in any
reform atory, jai l ,
or
penitentiary.
I certify under penalty of perjuryand pursuantto the lawsof the Stateo f Iowa that these facts aretrue and
correct.
L.F. NOLL, INC.
T. L.
NOLL, VICE
PRESIDENT
70 5
Douglas St., Suite
344
Sioux
City,
IA51101
712-252-0583
956733
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
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E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
6/15
N C S .
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E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
7/15
NCS,
INCDBA
NOLL COLLECTION SERVICE
AProfessional
Debt Collection Service Since
1965
705
DOUGLAS STREET, SUITE
344
SIOUX CITY,
IA
51101
(712)
252-0583
DATE:
014345
560897 S789.93 01/14/14
The
above debtor refuses
to
cooperate.
We
recommend further action,
in
order toenforce collection. Before our
attorney
ca nproceed, we willrequire:
* Completion of the
assignment
at the bottom of this page.
*Copy of the
itemized
statement showing balance due (if not
previouslyprovided
If the
original account
is a
contract
or
note,
we
must have
the
original.
ASSIGNMENT
EOR
PURPOSES
OF
SUIT
Forvaluable consideration, receipt hereby acknowledged, theundersigned
herebv
assign,transfer,
and set
over unto L.F. Noll, Inc. thatcertain claim against
SHERRYBAILEY
for
goods, wares
and
merchandise sold
and
delivered
or
services rendered
and
performed in theprincipal amount of S789.93
lawful
interest
thereon;
anddoes
hereby authorize said assignee
to do and
perform
all
acts
necessary
for
collection;commencement
of
suit
in the
name of
the
assignee,
settlement
,
adj stment,compromise orsatisfactionofsaid claim.Assignor
hereby certifies that said claim
is
justly
due and
owing
and
warrants
compliancewithrequirements
of the
Iowa
Consumer
Credit Code
as
well
as
disclosure an dother provisions oftruth inlending, andthat same is
free
of
set-offs andother defenses.
THISIS ANATTEMPTTO
COLLECT
ADEBT,
ANY INFORMATION OBTAINED WILL
BE
USED
FOR
THAT PURPOSE
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
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8/15
D O C T O R
GYANO, B . K.
I L L I N DA TE
09/06/13
PAGE
Lor in
Hospital
21 Highland
A ve
Sac
City
IA
50583
; E L E P H O N E
N O
712 660 1995
EX T EN S I ON
M ED R E C N O / A D M I SS I O N N O
22411 / 559148
NO .
I N S U R A N C E C OM PA N Y
POLICY
NUMBER
POLIC Y
HO LDER PLAN
07
05
B L U E
CROSS 140
SELF-PAY
XQH118AD7600
1 4 7 7
BAILEY SHERRY
BAILEY
S H E R R Y
ZTYCLE -0002
G U A R A N T O R
PATIENT NAME
MED.REC NO. /
ADMISSION
NO
SHERRYBAILEY
317 LEONARD ST
SACCITYIA50583
SHERRY
BAILEY
22411
/ 559148
PATIENT
TYPE
32
ADMISSIONDATE
07/18/13
DISCHARGE DATE BIRTHDATE
SEX
AGE
GUARANTOR IS
RESPONSIBLE
FOR ANY
AMOUNTS
DUE
AFTER
THE
INSURANCE
COMPANIES
MAKE THEIR PAYMENTS
D E S C R I P T I O N
ATE
08-06
08-08
08-01
08-06
08-08
08-01
08-06
08-08
08-12
08-15
08-21
08-01
08-12
08-15
08-21
PHYSICALTHERAPY
SUMMARY OF CHARGES
PHYSICAL THERAPY
TOTAL CHARGES
PREV
BALANCE
BALANCE
QUANTITY
C H A R G E
50 00
50 000
60 000
6
60 000
50 000
50 000
50 000
50 000
50 000
50 000
50 000
50 000
50 000
60 000
840
00
840 00
C P T
DEPT TOTAL
P A Y LAST
BALANCE
AMOUNT
50.00
50. 00
60 .00
60 . 00
60. 00
50. 00
50 .00
50 . 00
100.00
50.00
50. 00
50.00
50.00
50 .00
60 . 00
840.00
Moo oo
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
9/15
O T O R
GYANO , B.
K.
BILL ING DATE
08/06/13 PAGE
Lor i n
Hosp i t a l
K/
21 1 Highland Ave Sac Ci ty IA 50583
TELEPHONE N O
712-660-1995
E X T E N S I O N
MED R E C N O / A D M I
HCS
22411
/ 55914
S
N O
05
I N S U R A N C E C O M PA N Y
SELF-PAY
...~.
V0A9477
POLICY
H O L D E R
-..-- ,
^
BAILEY SHERRY
PL A N
_
wwv
/ <
G U A R A N T O R PAT IENT
NAME
MED R E C N O /A D M I S S IO N NO
SHERRY BAILEY
317LEONARDST
SACCITYIA 50583
SHERRY
BAILEY
22411
/ 559148
PATIENT
T Y P E
32
ADMISSION D A T E
07/18/13
DISCHARGE D A T E
B I R T H D A T E
flV MI 6
SEX AGE
44
G U A R A N T O R I S R E S P O N S I B L E F O R A N Y A M O U N T S D U E A F TE R T H E I N S U RA 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 S
D A T E
H R G E
O D E
D E S C R I P T I O N
QUANTITY
C H A R G E
CP T
A M O U N T
07-18
07-22
07-30
07-18
07-22
07-30
07-18
07-30
45 000
45.000
45.000
50 . 00
50
000
50 . 00
120
.
000
50.000
PHYSICALTHERAPY
DEPT
TOTAL
45.00
45 . 00
45.00
50.00
50 . 00
50 . 00
120.00
50.00
455.00
SUMMARY OF CHARGES
PHYSICAL THERAPY
TOTALCHARGES
PREV BALANCE
BALANCE
455
00
455 00
100.00
TtrO
00
P a o . o o
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
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D O C T O R
BILLING DATE
03 28 14
PAGE
Lorin Hospital
211 Highland Ave Sac City IA 50583
T E L E P H O N E
N O
712 661 8343
EXTENS ION
M E D R E C
S
MO
22411
/
O
INSURANCE COMPANY
BLUE CROSS140
SELF-PAY
POLICYNUMBER
XQH118AD7600
POLICY
HOLDER
BAILEY SHERRY
BAILEY SHERRY
PLAN
UARANTOR
MED. REC.NO. /
ADMISSION
NO
SHERRY BAILEY
317LEONARD
ST
SACCITYIA
50583
SHERRY BAILEY
22411
/
569997
P T I MT
T Y P E
11
A D M I S S I O N D A T E
03 20 14
DISCHARGE DAT E
03/20/14
BJRT HD AT E S EX
AGE
45
G UA R A N T O R I S R E S P O N S I B L E F O R A N Y A M O U N T S DU E A F T E R T HE I N S U RAN CE C O M P A N I E S M A K E T H E I R P AY M E N T S
D A T E
CHARGE
C ODE
D E S C R I P T I O N Q U A N T I T Y
C H A R G E
CRT
AMOUNT
03 20
3 2
3 2
03 20
03 20
3 2
03 20
03 20
03 20
3 2
03 20
EMERGENCYROOM
INFUSION/CHEMO
THE
LABORATORY
PHARMACY
IVSOLUTIONS
OXYGEN
711 000
102.000
54
.000
18.000
36 400
64.520
93.880
44.000
55.000
91.000
169.000
8
.000
99.820
28.350
50.000
DEPTTOTAL
DEPTTOTAL
DEPT TOTAL
DEPT
TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
711.00
711.00
102.00
162 .00
264 00
18 .00
36 40
64.52
93.88
44 . 00
55.00
91.00
402 80
169.00
169 00
16.00
99.82
115.82
28.35
28.35
50 00
50.00
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
11/15
O T O R Lorin
Hospital
PEK Z. L. *
BILLING DATE
\
?br
03/28/14
PAGE
2 21 1 Highland A ve Sac City IA 50583
TELEPHONENO.
EXTENSION
712-661-8343
MED.
REC.NO. / ADMISSION NO.
22411 /
569997
N O. IN S U RA N C E C OM P A N Y P OL IC YN U M B E R . POL ICY HOLDER PLAN
07 BLUE C R O S S 140 XQH118AD7600 BAILEY SHERRY
05 SELF
-PAY 9477 BAILEY
SHERRY
G U A R A N T O R
PATIENT NAME
MED. REC. NO. /
ADM I SSIO N
N O.
SHERRYBAILEY
SHERRY
BAILEY 22411/ 569997
PATIPNT
317
LEONARD
ST TYPE A D M I S S I O N D A T E D I S C H A R G E D A T E B IR T H D AT E , SEX A G E
SAC CITY
IA
50583
11 03/20/14 03/20/14 flMV68 F45
G U A R A N T O R IS R E S P O N S I B L E F O R A N Y A M O U N T S D U EAFTERT H EI N S U R 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 S ^ KJRSH^
D A T E
CHA RG E
C O D E
DESCRIPTION
SUMMARY OF
CHARGES
EMERGENCY ROOM
INFUSION/CHEMO
THERAPY
LABORATORY
EKG
PHARMACY
IV
SOLUTIONS
OXYGEN
TOTAL CHARGES
BALANCE
QUA NTI TY C H A R G E
71100
264 .00
402.80
169.00
115.82
28.35
50.00
1740.97
CR T
AMOUNT
1740
.97
~ < 3 . ( j D
o
-
ID^^
E-FILED 2014 NOV 03 2:31 PM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
12/15
D O C T O R
BLESSINGTON
KAY
BILLINGDATE
09/10/13
PAGE
Lorin Hospital
3
211Highland
Ave Sac
City
IA
5 583
..^LEPHONE
NO.
712 660 1995
EXTENSION
MED. REC. NO. /Al
22411
/ 560
O.
INSURANCE COMPANY
BLUE CROSS
140
SELF-PAY
POLICY NUMBER
XQH118AD7600
G U R N T O R
POLICY HOLDER
BAILEY SHERRY
BAILEY SHERRY
PLAN
- /
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
13/15
E-FILED 2014 NOV 26 11:24 AM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
14/15
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 SCSC015535
vs.
JUDGMENT ENTRYDefendant(s),
SHERRY L BAILEY225 12TH STREET APT 2-NVA-SAC CITY IA 50583
The court file shows that the defendant has received proper notice and has 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 in
the amount of $ 789.93 with interest at the rate of 2.10 % from the 3rd day of November, 2014 andcourt costs.The Court further enters judgment for prejudgment interest in the amount of $14.64.
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: $800.00
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E-FILED 2014 DEC 02 10:52 AM SAC - CLERK OF DISTRICT COURT
7/26/2019 SCSC015535 - Judgment against Sac City woman in the amount $789.93.pdf
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State of Iowa Courts
Case Number Case TitleSCSC015535 L F NOLL INC VS SHERRY L. BAILEYType: ORDER FOR JUDGMENT
So Ordered
Electronically signed on 2014-12-02 10:32:54
2 of 2
E-FILED 2014 DEC 02 10:52 AM SAC - CLERK OF DISTRICT COURT