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
ANGELA SANDERS
225S11THST
SAC CITY IA 50583
DUSTIN J. SANDERS
225S11THST
SAC 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 of you the amount of $773.82. 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
LOR1NG HOSPITAL
S1OUXLAND UROLOGY ASSOCIATES
TOTAL
PRINCIPAL
$733.64
$ 25.00
$758.64
PRE-FILING INTEREST
$14.52
$_ .66
$15.18
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 will 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 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.
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
/OfSSICAR. NOLLAT0008873
)5 Douglas St., Ste 502
Sioux City IA 51101
Phone (712) 224-2675
Fax (712) 252-4497
irn@decklaw.net
ATTORNEY FOR PLAINTIFF
0002837481
MAY 6,2014
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L. F. NOLL, INC.
PLAINTIFF
VS
ANGELA SANDERS
DUSTIN J. SANDERS
DEFENDANT(S)
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
NO.
For Defendant: ANGELA SANDERS
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 $773.82 is the balance due and owing as of MAY 6, 2014 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, ANGELA SANDERS, resides at 225 S 11TH ST SAC CITY IA 50583. 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.mil/appi/scra/scraHome.d_o.
n 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.
LF. NOLL, INC.
T. JXNOLL, VfCE PRESIDENT
705 Douglas St., Suite 344
Sioux City, 1A51101
712-252-0583
0002837481
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
NOTICE OF RIGHT TO CURE DEFAULT
HCS, INC DBA
NO.LL COLLECTION" SERVICE
705 DOUGLAS STREET, SUITE 344
PO .BOX 593
SIOUX, : CITY IA 51102-0593
(712)252-0583
APRIL 10, 2014
ANGELA SANDERS
DOSTIN SANDERS
225 S 13.TH ST '
SAC CITY IA 50583
[LISTED BELOW IF MORE T.H.AN ONE) '
TOTAL AMOUNT DUE: $773.82 . . v: = :> .
AMOUNT IN DEFAULT: $733.64
You .are .now in default on this credit transaction.; You have a right to. .;.
correct this default within 20 days. If you do so, y.ou, may continue with. che.
contract as though you did not default.. . , . . , ..,,,;. . . . ... _ . . _ .
'YOUR. DEFAULT CONSISTS OF:
Correct this default by:
FAILURE TO- PAY AS AGREED . , '
Paying 'the amount in default, $733. 64 to
Noll Collection Service, agent for the abo.ve
creditor.
. ; , If you do not correct this default- within 20 days')- we may exercise" bur-
rights against you under the law.. ' - - - - T . - .
If you default: again in the next year, we may exercise our rights .without'.
sending you another notice like this one. -\ f you haye-.any.ques.ti.ons, -write: .or
telephone, promptly.
Sincerjely,
L. Fi !Noll
THIS IS AN ATTEMPT TO COLLECT A DEBT, . . ' . :..
.: ANY AND ALL INFORMATION OBTAINED > IILL BE USED FOR THAT PURPOSE';
000283^481
-Client Name Client Ref No Principal Interest .Other
Tota'i
LORING, HOSPITAL 474118
LORING, HOSPITAL 5331S-5.
LORING; HOSPITAL 537128
SXOUXLAND UROLO 00419239
253.27
330.37'
iso.oa
25.00
f f . 2 8 .- .
5". 8'4 - : '
2^ .4 0 - .
,. 66: , .
.00
.00
.00
. 00
259,55
336. 21
152-. 4o,
25-66.
773.82
E-FILED 2014 MAY 12 3:34 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, ilA 51101
(712) 252-0583
DATE: APRIL 9, 2014
LORING HOSPITAL 014345
ATTN JAN WISEMAN
211 HIGHLAND AVE
SAC CITY IA 50583
ATTENTION:
RE: DUSTIN J SANDERS
474118 $733.64 12/29/08
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
DUSTIN J SANDERS
ANGELA SANDERS
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $733.64 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
LORING HOSPITAL
; QiMjJiAatfx04u
t / Na me a nd Of f i ci a l Ti t le)
. THIS.IS AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINEO'JWILL BE USED FOR THAT PURPOSE'
0002802519
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
PEK, Z. L.
BILLING DATE
03/05/12 PAGE
Lorin^ Hospital
TELEPHONE NO.
211 Highland Ave Sac City, !A 50583
712-299-2938
EXTENSION
MED, REC. NO. / ADMISSION NO.
30756 / 537128
NO INSURANCE COMPANY POLICY NUMBER POLICY HOLDER PLAN
07
05
BLUE CROSS 140
SELF-PAY
XQH331AD8081
480158326
SANDERS, DTJSTIN
SANDERS, DUSTIN
GUARANTOR PATIENT NAME
MED. REC. NO. / ADMISSION NO.
DUSTIN SANDERS
225 S 11TH STREET
SAC CITY IA 50583
DUSTIN SANDERS 30756 / 537128
PATIENT
13
ADMISSION DATE
02/ 28/ 12
DISCHARGE DATE
02/28/12
BIRTHDATE
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIESMAKE THEIR PAYMENTS
"DATE
CHARGE
CODE
DESCRIPTION QUANTITY CHARGE CPT
SEX
M
AGE
28
PAY LAST
BALANCE
AMOUNT
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
1
OBSERVATION ROOM
EMERGENCY ROOM
INFUSION/CHEMO THE
LABORATORY
PHARMACY
RADIOLOGY, PROFESS
RADIOLOGY, TECH
ULTRASOUND
IV SOLUTIONS
308.000
711.000
63. 000
72. 000
204 .000
67.000
12.000
17.720
44.000
47.500
87.830
87.830
96.710
8 .000
40.480
130.300
135 . 000
294 .000
13.060
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
308.00
308.00
711.00
711.00
276.00
72.00
204 . 00
67.00
619.00
12 . 00
17 .72
44 .00
47 .50
121.22
87 .83
87 .83
96.71
16.00
288.37
40 .48
130.30
170.78
135.00
135 .00
294.00
294.00
13 .06
13 .06
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
PER, 2. L.
BILLING DATE
03/0-6/12 PAGE
Loring- Hospital
211 Highland Ave Sac City, !A 50583
TELEPHONE NO.
712-299-2938
EXTENSION
MED, REG. NO. / ADMISSION NO.
30756 / 537128
NO, INSURANCE COMPANY POLICY HOLDER PLAN
07
05
BLUE CROSS 140
SELF-PAY
XQH331AD8081
48015892S
SANDERS, DUSTIN
SANDERS, DUSTIN
GUARANTOR PATIENT NAME MED. REC. NO. / ADMISSION NO.
DUSTIN SANDERS
225 S 11TH STREET
SAC CITY IA 50583
DUSTIN SANDERS 3075S / 537128
PATIENT
TYPE
13
ADMISSION DATE
02/28/12
DISCHARGE DATE
02/28/12
BIRTH DATE SEX
M
AGE
28
GUARANTOR.IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
CHARGE
CODE
DESCRIPTION QUANTITY CHARGE CPT
PAY LAST
BALANCE
AMOUNT
SUMMARY OP CHARGES
OBSERVATION ROOM
EMERGENCY ROOM
INFUSION/CHEMO THERAPY
LABORATORY
PHARMACY
RADIOLOGY, PROFESSIONAL
RADIOLOGY, TECH
ULTRASOUND
IV SOLUTIONS
TOTAL CHARGES
BALANCE
308 . 00
711. 00
619.00
121.22
288.37
170 .78
135.00
294.00
13 .06
2660.43
2650.43
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
" i V : ' . : . - ' . ' ' ; ^DOCTOR- V V ; ' ; >/: ^/; ; " LOlinCf HOSpltal ^TELEPHONE' NO. ^] ^EXTENSION.-.,'
MARCZEWSKI, L. J.
?S~
rx
06/ 20/ 08 PAGE 1 J 211Highland Ave
NO.
07
OS
vS3
. *
712-293-2998
; MEp;REC>^p. 7^ADMi SSlON' \NO/
Sac City, IA 50583 30756 /474118
: : \I^SURANcV oMPANY^-5 ^j^^QM^^
BLUE CROSS 140 NTI271AD5085
SELF-PAY _480158926
/} / /9 /$ * " '
LL'<>h' -o/l/> /c^-<f>y?^?'>
G Q ARANTOR' .'.'.;' ; >* . . Ir-i&tejfy'ti ^A'-Hs : '' ^; sM&+'';
DUSTIN SANDERS
225 S11THST
SAC CITY IA 50583
^gpOL]GY,^L5ER:;;;:i ^'^^^^^^
SANDERS, DUSTIN
SANDERS, DUSTIN
J'PAJJE NT NAM E';V;-,,'>; :^ : ^. % '; >' ' - /; "'.^ "*; Mq};;REcI j >J o-.: V .^VD Mi s 6) d N i NO ;
DUSTIN SANDERS 30756 /474118
:P^PEEN^:.
11
ADMISSfo'N;DAT-E. bfeCHARGE' bATE' .r' BmfHbATE" -' ^SEX;- '. AGE >V ' . ' : ' ,-
05/22/08 05/22/08 ^Ltf/83M 25
GUARANTOR- I S-RESPONSi BLE. >OR;A' NY' AMOUNTS pUEj AFT^i j ^fHEi j NSURA
' PATE'': '.
OS
05
05
05
-22
-22
-22
-22
05-22
- , ' CHARGE. V
' - ' " CODE '-'-'-
JHMHHb
~* mifmL
HUK
n mi ni
^'i" ': ': : ~^'" '' --. ,':?''*"' = 'DES;CRI FTJO'N^':;-:^
^^^b
EMERGENCY ROOM
j || !!Illllllllllllll
^mffiBBBQ
LABORATORY
IHMOT^H^MMW
MEDICAL SUPPLIES
SUMMARY OF CHARGES
EMERGENCY ROOM
LABORATORY
MEDICAL SUPPLIES
TOTAL CHARGES
BALANCE
:," i .^' 1_' \;L.:bl; ,
. N1
Q UANTJTY
1
1
1
1
1
V i cKARG^rv
231. 000
12. 000
44. 000
47. 500
1. 800
231. 00
116. 06
1. 80
348. 86
k-' . ^CPj ^-,:
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
&- ci /du O-
vV vV - : AMOUNT.;;.;' ; : : " ~,
231. 00
231. 00
12. 00
44. 00
47. 50
116.06
1. 80
1.80
348' . 86
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
f 1
DOCTOR
PEK, Z. L.
BILLING DATE
12/07/11 PAGE 1
NO.
05
~" Loring- Hospital -^
o yp^)
l\y\v?f
271 Highland Ave Sac City, IA 50583
INSURANCE COMPANY
SELF -PAY
POLICY NUMBER
611033380
GUARANTOR
ANGELA SANDERS
225 S 11TH ST
SAC CITY IA 50583
TELEPHONE NO. EXTENSION
712- 662- 4008
MED. REC. NO. / ADMISSION NO.
33093
POLICY HOLDER
SANDERS , QUINTE
PATIENT NAME
U.^_SANDERS
PATIENT
TYPE '
11
ADMISSION DATE
11/26/11
DISCHARGE DATE
11/26/11
PLAN
/ 533164
MED. REC. NO. / ADMISSION NO.
33093 / 533164
BIRTHDATE SEX AGE
W/^/08 M 2
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
11-26
11-26
CHARGE
CODE
DESCRIPTION
4MMfc *-

EMERGENCY
PHARMACY
SUMMARY
EMERGENCY
PHARMACY
ROOM

OF CHARGES
ROOM
TOTAL CHARGES
BALANCE
QUANTITY
1
1
CHARGE
308.00
22.37
308. 00
22.37
330.37
CPT
DEPT TOTAL
DEPT TOTAL
PAY LAST
BALANCE
AMOUNT
308. 00
308.00
22.37
22.37
330. 37
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
NCS, INC DBA
NOLL COLLECTION SERVICE
"A Professional Debt Collection Service Since 19SS"
705 DOUGLAS STREET, SUITE 344
SIOUX CITY, IA 51101
(712) 252-0583
DATE: APRIL 9, 2014
SIOUXLAND UROLOGY ASSOCIATES 025500
P 0 BOX 2020
NORTH SIOUX CITY SD 570492020
ATTENTION:
RE: DUSTIN J SANDERS
00419239 $25.00 09/14/12
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
DUSTIN J SANDERS
ANGELA SANDERS
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $25.00 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.
'-?'- ^-, 7
day of=4>3>\ [/. Dated this ": day of_^,/iA j (^ , 20 / S
SIOUXLAND UROLOGY ASSOG'IATESX
-f / " 1x7
By: U^^<L+
{Name and Official TitleT --
THIS ISCftN ATTEMPT TO COLLECT A DEBT,
"" INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
000291S871
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
Account Ledger
Siouxland Urology Associates
P.O. Box 2020
Dakota Dunes, SD 57049
Phone: (605)217-7010
Dustin Sanders
225 S 11th St
Sac City, IA 50583
Tax ID; 420982360
Account: 00419239
Responsible Party: Self
Insurance 1 (XQH331AD8081) BCBS Iowa Wellmark
Home Phone: (712) 662-4008
Work Phone:
Primary Provider: (9) Timothy Kneib
Referring Physician: (689) Zoitan Pek
Patient,Balance
M
j Insurance Pending
Type Provider
BUI
Status Service Date Code # Description Charge Payment Adj
C (9) Kneib
I (9)Knerib
A (9) Kneib
A (9) Kneib
MMemo
MMemo
Visit Entry Date: 03/09/2012
Bill' , 03/29/2012,03/29/20123 - , ttO>BeBSrlowabWellmark "^ t '
" '""' "J i * IHM' i f " , 0034108599 1
Bill Q3/2Ql2fy\2 03/29/2012 CO45 J ' -, 0 .Charges^xceed contracted fee
Bill 09/17/2012 09/1,7/2012 cj., ' ^ " " 0' CoIlebtibnWnte Off
03/09/2012 Ins Code sequence on visit [3]; by user:
DBertrand
03/29/2012 $25.00 applied to co-payment
Visit Balance: $0.00 $188.00
00 > ,r
($135.00) J
($28.00;
1 ' ($25 00]
($135.00) ($53.00)
C = Charge; I = Insurance Payment; P = Private Payment; A = Adjustment; F = Insurance Filing; M= Memo
Showing: All Visits
Indicates a preliminary (open) transaction that is subject to review.
4/9/2014 2:26:47 PM Created by: VJauer
ID: 17 Ver 1.15.2.9 Page 1 of 1
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L. F. NOLL, INC.
PLAINTIFF
VS
ANGELA SANDERS
DUSTIN J. SANDERS
DEFENDANT(S)
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
NO.
For Defendant: DUSTIN J. SANDERS
1. I, T. L. Noll, Vice President of L. F. Noli, 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 staternent(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 $773*82 is the balance due and owing as of MAY 6, 2014 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, DUSTIN J. SANDERS, resides at 225 S 11TH ST SAC CITY IA 50583. is
employed at PU\NTINUM ETHANOL 2585 QUAIL AVE ARTHUR IA 51431. 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/scraHome.do.
D Contacting Defendant who informed me, or
n Regularly seeing Defendant and believing Defendant is not active in the U.S. military.
OR B. 0 I have investigated, and 1 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, IN
T. L NOCL, Vf&E PRESIDENT
705 Douglas St., Suite 344
Sioux City, IA51101
712-252-0583
0002837481
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
NOTICE OF RIGHT TO CURE DEFAULT
NCS, INC DBA
NOLL COLLECTION SERVICE
705 DOUGLAS STREET, SUITE 344
PO BOX 593
SIOUX CITY IA 51102-0593
{712)252-0583
APRIL 10, 2014
ANGELA SANDERS
DUSTIN SANDERS
225 S 11TH ST
SAC CITY IA 50583
RE: (LISTED BELOW IF MORE THAN ONE)
TOTAL AMOUNT DUE: $773.82
AMOUNT IN DEFAULT: $733.64
You are now In default on this credit transaction.. You have a right to
correct this default within 20 days. If you do so, y.ou. may continue with the
contract as though you did not default.
'YOUR DEFAULT CONSISTS OF:
Correct this default by:
FAILURE TO PAY AS AGREED
Paying the amount in default, $733.64 to
Noll Collection Service, agent for the above
creditor.
- . If you do not correct this default within 20 days; - we may exercise1 our
rights against you under the law.
If you default again in 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,
L. F. Noll
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY AND ALL INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
0002837481
-Client Name Client Ref No Principal Interest Other Total
LORING HOSPITAL
LORING HOSPITAL
LORING HOSPITAL
SIOUXLAND UROLO
474118
533164
537128
00419239
253,
330,
150.
25.
.27
,37
,00
.00
6.
5".
2.
28
84-
40
66. . ,
.00
.00
,00
.00
259.
336.
152,
25,
,55
,21 '
.40.
.66.
773.82
E-FILED 2014 MAY 12 3:34 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,ilA 51101
(712) 252-0583
DATE: APRIL 9, 2014
LORING HOSPITAL 014345
ATTN JAN WISEMAN
211 HIGHLAND AVE
SAC CITY IA 50583
ATTENTION:
RE: DUSTIN J SANDERS
474118 $733.64 12/29/08
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
DUSTIN J SANDERS
ANGELA SANDERS .
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $733.64 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 f4 day of ft^_ , 20
LORING HOSPITAL
^Name and Official Title)
. THIS.IS_ AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINED'-JWILL BE USED FOR THAT PURPOSE".
0002802519
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
PEK, Z. L.
BILLING DATE
03/06/12 PAGE
Loring Hospital
TELEPHONE WO.
211 Highland Ave Sac City, !A 50583
712-299-2998
EXTENSION
MED. REG. MO. / ADMISSION NO.
30756 / 537128
NO INSURANCE COMPANY POLICY NUMBER PO'LICY HOLDER PLAN
07
05
BLUE CROSS 140
SELF-PAY
XQH331AD3081
480158926
SANDERS, DUSTIN
SANDERS, DUSTIN
GUARANTOR PATIENT NAME MED. REC. NO. / ADMISSION NO.
DUSTIN SANDERS
225 S 11TH STREET
SAC CITY IA 50583
DUSTIN SANDERS 30756 / 537128
PATIENT
TYPE
13
ADMISSION DATE
02/28/12
DISCHARGE DATE
02/28/12
BIRTHDATE
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
'DATE
CHARGE
CODE
DESCRIPTION QUANTITY CHARGE CRT
SEX
M
AGE
28
PAY LAST
BALANCE
AMOUNT
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
02-28
OBSERVATION ROOM
EMERGENCY ROOM
INFUSION/CHEMO THE
LABORATORY
PHARMACY
RADIOLOGY, PROFESS
RADIOLOGY, TECH
ULTRASOUND
IV SOLUTIONS
1 308 . 000
711.000
69.000
72. 000
204. 000
67. 000
12.000
17.720
44. 000
47.500
87. 830
87 . 830
96.710
8. 000
40.480,
130.300:
135.000
294.000
13.060
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
308.00
308.00
711.00
711.00
276.00
72. 00
204.00
67. 00
619.00
12 . 00
17.72
44. 00
47.50
121.22
87.83
87. 83
96.71
16.00
288 .37
40.48
130 .30
170.78
135.00
135.00
294 .00
294.00
13. 06
13. 06
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
J D O C T O R Loring" Hospital
PEK, Z. L. <>-%-
B I L L I N G D AT E j\
03/0.6/12 PAGE 2 J 211 Highland Ave Sac City, 1A 50583
, T ELEPHO N E N O . EXT ENSIO N
712-299-2998
MED . R EC . N O . / A D MI SSI O N N O .
30756 / 537128
N O . I N SUR AN C E C O MPAN Y PO LI C Y N U MB ER PO LI C Y HO L D ER PLAN
07 BLUE C R O SS 140 XQH331AD 8081 SAN D ER S, D UST I N
O S SELF-PAY 480158926 SAN D ER S, D UST I N
G UAR AN T O R PAT I EN T N AME MED . R EC . N O . / AD MI SSI O N N O .
D UST IN SAND ER S D UST IN SAND ER S 30756 / 537128
225 S 11T H ST R EET ^T Yp^"" AD MI SSI O N D AT E D ISC HAR GE D AT E B I R T HD AT E SEX AGE
SAC C IT Y IA 50583 13 02/28/12 02/28/12 **/^/83M 28
G UAR AN T O R .IS R ESPO N SI B LE FO R AN Y AMO UN T S D UEAFT ER T HE I N SUR AN C E C O MPAN I ES MAKE T HEI R PAYMENT S
D AT E
:
C HAR G E
C O D E
5'i//3-
ef t&
D ESC R I PT I O N
SUMMAR Y O F C HAR G ES
O B SER VAT I O N R O O M
EMER GENC Y R O O M
I N FUSI O N /C HEMO T HER APY
LAB O R AT O R Y
PHAR MAC Y
R AD I O LO G Y, PR O FES S IO NAL
R AD I O LO G Y, T EC H
ULT R ASO UND
I V SO LUT I O N S
T O T AL C HAR GES
BALANC E
/S\>^>-^ ^o^^I ) ^^3
QUAN T I T Y

C HAR G E
308. 00
711.00
619.00
121.22
288.37
170. 78
135.00
294. 00
13.06
2660.43
-
C PT
^ \i'\a "^
A
/) y-,r\p-4
eP
<f A-
PAY LAST
BALANC E
AMO UN T
2660.43
<^V^ .^e^
I~IO),70
/5DOO
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
D O C T O R . . Loring- Hospital ^ ^ C ^ P HO N ^ N C ^ - ^ E X T E N S I O N ^
MAR C ZE WS KI , L. J.
B I LLI N G D AT E '
^c/br
06/ 20/ 08 PAGE 1 J 211 Highland Ave - S ac City, IA 50583
712- 299- 2998
^ ME D ^ R E C ^NO ". 7:&bMiS S I O N ''N O ;^
30756 /474118
N O I N S U R AN C E . C O MP AN Y " - , , P Q UC Y. N UMB E R ; " P O LI C Y HO LD E R P LAN "
07 BLUE C R O S S 140 N T I 271AD 5085
05 S E LF- P AY ,,480158926
/i X /^ 7 $ ~ ~ '
GUAR AN T O R . / , " *" > "
D US T I N S AND E R S
225 S 11T H S T
S AC C I T Y I A 50583
S AN D E R S , D US T I N
S AND E R S , D US T I N
PAT I E NT N AME rr." > > ME D R E C N O / AD MI S S I O N N O
- P AT I E N T ^
r'.'tT YPE *- ?'"-
11
D US T I N S AND E R S 30756 /474118
AD Ml^ jpN lB AT E . D 'lS C HA'ftGE '.'D AT E - ''.: B I R T H D AT E - ";:'" -S^, -/AGE?- i,; /' :\
05/22/08 05/ 22/ 08 4/0/83M 25
G UAR AN T O R - I S - R E S P O WS I B LE FO R AN Y AMO UN T S D UE 'AFT E R T HE I N S UR AN C E C O MP AN I E S MAKE T HE I R P AYME N T S
;'! - D AT E ) :
05- 22
05- 22
05- 22
05- 22
05- 22
' - . 'C HAR G E
.' '"C O D E -
40HHH*
a0M
" D E S C R I P T I O N
E ME R GE N C Y R O O M
LABO R AT O R Y
ME D I C AL S UP P LI E S
S UMMAR Y O F C HAR GE S
E ME R GE N C Y R O O M
LABO R AT O R Y
ME D I C AL S UP P LI E S
T O T AL C HAR GE S
BALANC E
* " * >
i
QUAN T I T Y
1
1
1
1
1
1
. C HAR G E
231.000
12. 000
12.560
44. 000
47. 500
1.800
231.00
116.06
1.80
348'. 86
C P T
D E P T T O T AL
D E P T T O T AL
D E P T T O T AL
- >9.- C &
15c0.ft
PAY LAS T
BALANC E
AMO U N T
231.00
231. 00
12.00
12.56
44. 00
47. 50
116.06
1.80
1.80
348'. 86
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
v ^
DOCTOR
PEK, Z. L.
BILLING DATE
12/07/11 PAGE 1
NO.
05
Lorinf Hospital ^
Q^ *"
ft A
"1
^
v?f
21 1 Highland Ave Sac City, IA 50583
INSURANCE COMPANY
SELF -PAY
POLICY NUMBER
611033380
GUARANTOR
ANGELA SANDERS
225 S 11TH ST
SAC CITY IA 50583
TELEPHONE NO. EXTENSION
712-662-4008
MED. REC. NO. / ADMISSION NO.
33093
POLICY HOLDER
SANDERS , QUINTE
PATIENT NAME
:MSANDERS
PATIENT
TYPE
11
ADMISSION DATE
11/26/11
DISCHARGE DATE
11/26/11
FLAN
/ 533164
MED. REC. NO. / ADMISSION NO.
33093 / 533164
BIRTHDATE SEX AGE
&/9/QBM 2
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
11-26
11-26
CHARGE
CODE
OTMt
MMV
DESCRIPTION
JBMMIfc-
EMERGENCY
VMM^MW
PHARMACY
SUMMARY
EMERGENCY
PHARMACY
ROOM
I
OP
^i^Hi^Hh.
CHARGES
ROOM
TOTAL CHARGES
BALANCE
QUANTITY
1
1
CHARGE
308 .000
22.370
308 .00
22.37
330.37
CPT
DEPT TOTAL
DEPT TOTAL
PAY LAST
BALANCE
AMOUNT
308. 00
308.00
22.37
22.37
330.37
E-FILED 2014 MAY 12 3:34 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) 2S2-0583
DATE: APRIL 9, 2014
SIOUXLAND UROLOGY ASSOCIATES 025500
P O BOX 2020
NORTH SIOUX CITY SD 570492020
ATTENTION:
RE: DUSTIN J SANDERS
00419239 $25.00 09/14/12
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
DUSTIN J SANDERS
ANGELA SANDERS
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $25.00 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 day of^jtnA j i i ~ , , 20_/_4
SIOUXLAND UROLOGY ASSOG!
/ f>
(Name and Official TitleJ
U /~
THIS IS<^kN ATTEMPT TO COLLECT A DEBT,
'INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
0002915871
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
Account Ledger
Siouxland Urology Associates
P.O. Box 2020
Dakota Dunes, SD 57049
Phone: (605)217-7010
Dustin Sanders
225 S 11th St
Sac City, IA 50583
Tax ID: 420982360
Account: 00419239
Responsible Party: Self
Insurance 1 (XQH331AD8081) BOBS Iowa Wellmark
Home Phone: (712) 662-4008
Work Phone: Referring Physician: (689) Zoltan Pek
Type Provider^
Bill
Status Service Date Code # Description Charge Payment Adj
C (9) Kneib
I (9) Kneib
A {9) Kneib
A (9)Kneib
M Memo
M Memo
Bill
Bil l
Bill
-03/06/2012 03/06/2012*
03/29/2012 03/29/2012-3
$18800
Bil l
~ ~ 03/09/2012
03/29/2012
owa Wellmark
, 0034108599
0 ^Charges,, exceed contracted fee
^schedule! ^ t j ,
, 0 Collection Write Off; __
Ins Code sequence on visit [3]; by user:
DBertrand
$25.00 applied to co-payment.
($13500)
03/29/2032 03/29/2012 CO45.
' i i
09/17/2012 09/17/2012 C ( '
($28 00)
($25 00]
Visit Entry Date: 03/09/2012
Visit Balance: $0.00 $188.00 ($135.00) ($53.00)
'iifc^p'p;.^?:1^
C = Charge; I = Insurance Payment; P = Private Payment; A = Adjustment; F = Insurance Filing; M = Memo
Showing: All Visits
Indicates a preliminary (open) transaction that is subject to review.
4/9/2014 2:26:47 PM Created by: VJauer
ID: 17 Ver 1.15.2.9 Page 1 of 1
E-FILED 2014 MAY 12 3:34 PM SAC - CLERK OF DISTRICT COURT
E-FILED 2014 MAY 23 10:44 AM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY


Plaintiff(s), SMALL CLAIMS DIVISION

L F NOLL INC
PO BOX 593
SIOUX CITY IA 51102

Case: 02811 SCSC015434

vs.
JUDGMENT ENTRY
Defendant(s),


ANGELA R BARAIBAR
225 S 11TH ST
SAC CITY IA 50583
DUSTIN J SANDERS
225 S 11TH ST
SAC CITY IA 50583-0



The court file shows that the defendants have received proper notice and have 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)
, in the amount of $758.64 with interest at the rate of 2.11% from the 12th day of May ,2014 and
court 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 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: $600.00
1 of 2
E-FILED 2014 JUN 06 12:48 PM SAC - CLERK OF DISTRICT COURT
State of Iowa Courts
Case Number Case Title
SCSC015434 L F NOLL INC VS SANDERS ANGELA AND DUSTIN J
Type: ORDER FOR JUDGMENT
So Ordered
Electronically signed on 2014-06-06 12:48:41
2 of 2
E-FILED 2014 JUN 06 12:48 PM SAC - CLERK OF DISTRICT COURT