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E-FILED 2013 NOV 13 4:31 PM SAC - CLERK OF DISTRICT COURT

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

ORIGINAL NOTICE AND PETITION FOR A MONEY JUDGMENT

LARRY G. BLEVINS 351 S STATE RD PO BOX 284 LAKE VIEW IA 51450-0284

NO.

KELSEY BLEVINS 351 S STATE RD PO BOX 284 LAKE VIEW IA 51450-0284 DEFENDANT(S) To Defendant(s): 1. You are notified that the above-named Plaintiff demands of you the amount of $1066.08. 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 MARIE C. G'SELL, DOS TOTAL PRINCIPAL $ 36.88 $1028.28 $1065.16 PREFILING INTEREST $ .92 $0.00 $ .92

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 will receive electronic notification through EDMS of the place and time of the hearing on this matter. 5. If you electronically file, EDMS wit! serve a copy of the Appearance and Answer on Plaintiff(s) or on the attorney(s) for Plaintiff(s). The Notice of Electronic Filing will indicate if Plaintiffs) 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.

E-FILED 2013 NOV 13 4:31 PM SAC - CLERK OF DISTRICT COURT

R. NOLL AT0008873 705 Douglas St., Ste 502 Sioux City IA 51101 Phone (712) 224-2675 Fax (712) 252-4497 irn@decklaw.net ATTORNEY FOR PLAINTIFF

0002941746
NOVEMBER 7, 2013

E-FILED 2013 NOV 13 4:31 PM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT FOR SAC COUNTY SMALL CLAIMS DIVISION VERIFICATION OF ACCOUNT IDENTIFICATION OF JUDGMENT L. F. NOLL, INC. DEBTOR AND CERTIFICATE RE PLAINTIFF MILITARY SERVICE VS NO. LARRY G.BLEVINS For Defendant: LARRY G. BLEVINS KELSEY BLEVINS DEFENDANT(S)

1. I, T. L. Noll, 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 $1066.08 is the balance due and owing as of NOVEMBER 7, 2013 from Defendant(s) to Plaintiff(s) and any interest amount owing is accurately stated in the Petition and Original Notice. 2. I further state that Defendant, LARRY G. BLEVINS. resides at 351 S STATE RD PO BOX 284 LAKE VIEW lA 51450-0284. is employed at PROLIANT HWY 20 & MAIN ST LYTTON IA 50561. 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, I 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/appj/scra/scraHome.do. a Contacting Defendant who informed me, or a 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, INC.

T. L NOLbf^iCE PRESIDENT 705 Douglas St., Suite 344 Sioux City, IA51101 712-252-0583

0002941746

E-FILED 2013 NOV 13 4:31 PM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT FOR SAC COUNTY SMALL CLAIMS DIVISION L F. NOLL, INC.
PLAINTIFF VS NO. LARRY G. BLEVINS KELSEY BLEVINS DEFENDANT(S) For Defendant: KELSEY BLEVINS VERIFICATION OF ACCOUNT IDENTIFICATION OF JUDGMENT DEBTOR AND CERTIFICATE RE MILITARY SERVICE

1. I, T. L. Noll, 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 $1066.08 is the balance due and owing as of NOVEMBER 7, 2013 from Defendant(s) to Plaintiff(s) and any interest amount owing is accurately stated in the Petition and Original Notice. 2. I further state that Defendant, KELSEY BLEVINS. resides at 351 S STATE RD PO BOX 284 LAKE VIEW IA 51450-0284. is employed at , 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, I 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.mii/appi/scra/scraHorne.do. n Contacting Defendant who informed me, or a 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.

T. L. NOLL, VICE PRESIDENT 705 Douglas St., Suite 344 Sioux City, IA51101 712-252-0583

0002941746

E-FILED 2013 NOV 13 4:31INC PM SAC NCS, DBA - 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 FEBRUARY 21, 2013 LARRY G BLEVINS KELSEY BLEVINS PO BOX 284 LAKE VIEW IA 514500284

CREDITOR: LISTED BELOW IF MORE THAN ONE LORING HOSPITAL ACCOUNT NO. 0002927509 TOTAL AMOUNT DUE: $37.80 AMOUNT IN DEFAULT: $37.80 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, $37.80 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,

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 $36.88

INTEREST $0.92

OTHER $0.00

TOTAL $37.80

INC E-FILED 2013 NOV NCS, 13 4:31 PM DBA SAC - CLERK OF DISTRICT COURT NOLL COLLECTION SERVICE "A Professional Debt Collection Service Since 1965" 705 DOUGLAS STREET, SUITE 344 SIOUX CITY, IA 51101 (712) 252-0583

DATE: OCTOBER 21, 2013 LORING HOSPITAL ATTN JAN WISEMAN 211 HIGHLAND AVE SAC CITY IA 50583 ATTENTION: RE: LARRY G BLEVINS 543691 $36.88 02/19/13 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 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 LARRY G BLEVINS KELSEY BLEVINS for goods, wares and merchandise sold and delivered or services rendered and performed in the principal amount of $36.88 plus 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 p s T day offcj>MA_._
LORING HOSPITAL

014345

, 20

(Name and Of ficial Title) THIS IS AN ATTEMPT TO COLLECT A DEBT, ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. 0002927509

DOCTOR

MARCZEWSKI, L.
BILLING DATE

E-FILED 2013 NOV 13 4:31 PM SAC -ital CLERK OF DISTRICT COURT NO. TELEPHONE J. 712-6S7-2563

08/01/12
NO.

PAGE

211 Highland Ave -Sac City, IA 50583 POLICY NUMBER POLICY HOLDER

wc^
PATIENT NAME
PTYPEIT

EXTENSION

MED. REC. NO. / ADMISSION NO. 24994 / PLAN 543691

INSURANCE COMPANY

07 BLUE CROSS 140 05 SELF-PAY

MJP322AD0036 481068468

BLEVINS, LARRY BLEVINS, LARRY

GUARANTOR

LARRY G BLEVINS
PO BOX 284 LAKE VIEW IA

LARRY G BLEVINS

MED. REC. NO. / ADMISSION NO. 24994 / 543691
BIRTHDATE SEX AGE

ADMISSION DATE DISCHARGE DATE

51450

11

07/26/12

07/26/12

1/84 M

27

GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS DATE

PAY LAST BALANCF AMOUNT

DESCRIPTION

QUANTITY

CHARGE

CPT

07-26 3100002 07-26

LEVEL 1 EMERGENCY ROOM

231.000 183.620

DEPT TOTAL 82.990

231.00 183.62 414.62 82.99 82.99

07-26 PHARMACY

DEPT TOTAL

SUMMARY OF CHARGES EMERGENCY ROOM PHARMACY TOTAL CHARGES

414 . 6 2

82.99 497.61

BALANCE

497.61

NCS, INCSAC DBA- CLERK OF DISTRICT COURT E-FILED 2013 NOV 13 4:31 PM 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 NOVEMBER 7, 2013 LARRY G BLEVINS KELSEY BLEVINS 351 S STATE RD PO BOX 284 LAKE VIEW IA 514500284 CREDITOR: LISTED BELOW IF MORE THAN ONE MARIE C G'SELL, DDS ACCOUNT NO. 0002939504 TOTAL AMOUNT DUE: $1028.28 AMOUNT IN DEFAULT: $1028.28 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, $1028.28 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,

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 MARIE C G'SELL, DDS

PRINCIPAL $1028.28

INTEREST $0.00

OTHER $0.00

TOTAL $1028.28

E-FILED 2013 NOV 13 4:31 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: OCTOBER 21, 2013 MARIE C G'SELL, DOS
1406 N US HWY 71 CAROLL, IA 51401

015797

ATTENTION: RE: LARRY G BLEVINS BL0035 $1028.28 08/08/13 The above debtor refuses to coopera-t-e.- We recoinmend 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

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 LARRY G BLEVINS KELSEY BLEVINS for goods, wares and merchandise sold and delivered or services rendered and performed in the principal amount of $1028.28 plus 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 3 day of MARIE C G'SELL, DDS (Name and Official Title) THIS IS AN ATTEMPT TO COLLECT A DEBT, ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. 0002939504

C.,

E-FILED 2013 NOV 13 4:31 PM SAC - CLERK OF DISTRICT COURT

SINGLE PATIENT LEDGER
CARROLL DENTAL ASSOCIATES Date: 07/19/2013 Patient Name: Larry G Blevins 351 S State Rd PO Box 284 Lake View, IA 51450 Chart Number:BL0035 Page: 1

Billing Type: 1
PATIENT

DATE

TEETH

DESCRIPTION

CHARGE

PAYMENT

BALANCE

1 2/05/201 2 * 12/06/2012 * 12/06/201 2 * 12/13/2012 * 12/1 3/201 2 •12/13/2012 * 12/13/2012 * 12/13/2012 * 12/21/2012 * 12/21/2012 * 12/21/2012 * 12/21/201 2 * 12/21/2012 * 12/26/2012 * 12/26/2012 '12/26/2012 * 12/26/20 12 * 12/26/2012 * 01/07/2013 * 01/07/2013 * 01/07/2013 04/27/2013 05/24/2013 06/23/2013

Patient Balance Forward Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry Larry

9 10 11 12 UL 18 18 19 19 LL 14 15 20 21

,___,_. Dental Ins Payment - Delta Dental of Iowa

0.00 50.00 115.00 150.00 185.00 195.00 118.00 184.00 85.00 85.00 85.00 85.00 184.00

-165.00 85.00 130.00 130.00 118.00 -247.04 -364.00 -223.96
14.76 14.76 14.76

Dental Ins Payment - Delta Dental of Iowa Dental Ins Payment - Delta Dental of Iowa Dental Ins Payment - Delta Dental of Iowa Finance Charge Finance Charge Finance Charge

0.00 50.00 165.00 315.00 500.00 695.00 813.00 997.00 1082.00 1167.00 1252.00 1337.00 1521.00 1356.00 1441.00 1571.00 1701.00 1819.00 1571.96 1207.96 984.00 998.76 1013.52 1028.28

TOTAL PATIENT BALANCE AS OF 07/19/2013:

1028.28

Procedures that have been placed in History.

E-FILED 2013 DEC 16 1:11 PM SAC - CLERK OF DISTRICT COURT

E-FILED 2013 DEC 16 1:11 PM SAC - CLERK OF DISTRICT COURT

E-FILED 2013 DEC 19 2:03 PM SAC - CLERK OF DISTRICT COURT

E-FILED 2013 DEC 30 9:46 AM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

Plaintiff(s), LF NOLL, INC 705 DOUGLAS ST, STE 344 SIOUX CITY IA 51101

SMALL CLAIMS DIVISION Case: 02811 SCSC015368

vs. JUDGMENT ENTRY Defendant(s), KELSEY KAY BLEVINS 351 S STATE RD-NVALAKE VIEW IA 51450 LARRY GENE BLEVINS PO BOX 284 LAKE VIEW IA 51450

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(s) Larry Blevins, in the amount of $1065.16 with interest at the rate of 2.12% from the 13th day of November ,2013 and court costs. The Court further enters judgment for prejudgment interest in the amount of $0.92.

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. Fee:$185.00

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E-FILED 2013 DEC 30 9:46 AM SAC - CLERK OF DISTRICT COURT

State of Iowa Courts Case Number SCSC015368 Type: Case Title L.F. NOLL, INC. VS BLEVINS, LARRY AND KELSEY ORDER FOR JUDGMENT So Ordered

Electronically signed on 2013-12-30 09:46:51

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