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
JUSTIN A. BUSCHMANN
710 S 9TH ST
SAC CITY IA 50583-2236
TAYLOR J. BUSCHMANN
710S9THST
SAC CITY IA 50583-2236
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 $1161.90. 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
$1137.60
PRE-FILING INTEREST
$24.30
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.Jowacourts.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 30 4:12 PM SAC - CLERK OF DISTRICT COURT
f
siCA R. NOLL AT00088^3
Douglas St., Ste 502' j?.(
. - . . Sioux City IA51101 >'
-"Phorie;(712) 224-2675 -"V
Fax (712) 252-4497 ^
irnfojdecklaw.net . : 5*1-
ATTPRNEY FOR PLAINTIFF^;
0002810456 ' : ^: '.,
MAY 27, 2014 ';'; . ' " ' ' .
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L. F. NOLL, INC.
PLAINTIFF
VS
JUSTIN A. BUSCHMANN
TAYLOR J. BUSCHMANN
DEFENDANT(S)
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
NO.
For Defendant: JUSTIN A. BUSCHMANN
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 $1161.90 is the balance due and owing as of MAY 27, 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, JUSTIN A. BUSCHMANN, resides at 7105 9TH ST SAC CITY IA 50583-
2236. is employed at LORING HOSPITAL 211 HIGHLAND AVE SAC CITY !A 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, 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.o5d.mi!/appi/scra/scraHome.do.
n Contacting Defendant who informed me, or
n Regularly seeing Defendant and believing Defendant is not active in the U.S. military,
have investigated, and I am unable to determine whether or not Defendant is in the military OR B. O
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. LrTNOLL, VICE PRESIDENT
705 Douglas St., Suite 344
Sioux City, IA51101
712-252-0583
0002810456
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
NOTICE OF RIGHT TO CURE DEFAULT
NC5, INC DBA
MOLL COLLECTION SERVICE
705 DOUGLAS STREET, SUITE 344
PO BOX 593
SIOUX CITY IA 51102-0593
(712)252-0583
APRIL 24, 2014
JUSTIN A BUSCHMANN
TAYLOR J BUSCHMANN
710 S 9 ST
SAC CITY IA 50583-2236
RE: (LISTED BELOW IF MORE THAN ONE)
TOTAL AMOUNT DUE: $1161.90 . . . .
AMOUNT IN DEFAULT: $1161.90 ..
You are now in default- on this credit transaction. You have a right to
correct this default within 20 days. If you do so, you. may continue with' the
contract as though you d id not default. . . . . .
YOUR DEFAULT CONSISTS OF:
Correct this default by:
FAILURE TO PAY AS AGREED
Paying the amount in default, $1161.90 to
Noll Collection Service/ agent for the above
creditor.
If you do not correct this default within 20 days, we may exercise 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.
0002810456
Client Name Client Ref No Principal Interesi Other Total
LORIHG
LORING
LORING
LORING
LORING
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
538605
554219
555406
556988
560165
30
331
173
426
175
188
.94
.67
.11
.00
8
3
7
4
.49 "
.09 '
.26
.76 .. ,
.70 .
.00
' .00
.00
.00
.00
31.
340.
176.
433.
179.
37
03
93
87
70
1,161.90
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
NCS, INC DBA " '
NOLL COLLECTION SERVICE
"A Professional Debt Collection Service Since 196511
705 DOUGLAS STREET, SUITE 344
SIOUX CITYr IA 51101
(712) 252-0583
DATE: APRIL 23, 2014
LORING HOSPITAL 014345
ATTN JAN WISEMAN
211 HIGHLAND AVE
SAC CITY IA 50583
ATTENTION:
RE: JUSTIN A BUSCHMANN
538605 ^1-3.7.60 08/27/12
The above debtor refuses to cooperate. We recommend further action, in
order to enforce collection. Before our attorney ca?i~^qceed, 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
JUSTIN A BUSCHMANN
TAYLOR J BUSCHMANN
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $1137.60 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^ d a y o f A} . , 20
LORING HOSPITAL
(Name and Official Title)
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
0002914261
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
D O C T O R Loring" Hospital _ T E LE P HO N E N O .
P E K, 2. L.
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B I LLI N G D A T E J\\P 712-661-9590
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E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
MARCZEWSKI, L. J.
B I L L I N G DATE
04/05/12 PAG E
L oring" Hospital
' TE L E P H ON E
211 Highland Ave Sac City, IA 50583
712-661-9590
. .E X TE N S I ON
22756 / 53860S
O. I N S URAN CE COMP AN Y POLICY''NUMBER ' -pQUcV OL DE R P L AN
NATIONWIDE SPEC HEALTH
SELF-PAY
QLF00812823
481131762
BUSCHMANN, JUST
BUSCHMANN, JUST
UARAN TOR P ATIE N T N AME
^ME D.-RE C, N O. ' / ADMI S S I ON N O
JUSTIN A BUSCHMANN
710 SOUTH 9TH STREET
SAC CITY IA 50583
JUSTI N A B USCHMAN N 22756 / 538605
P ATI E N T
TYP E '
20
ADMI S S I ON DATE
03/30/12
DI S CH AH GE ' DATE
03/30/12
BiRTH DATE ' S E X
M
AGE
27
GUARAN TOR IS RE S P ON S I BL E FOR AN Y^AMOUN TS ' DUE ;A;FTE RTH E JN sURAN C^COf^P Afs||tS ;MAkE :TH E I R;P AYME N TS ' :-
DATE
CH ARGE
CODE
.: DE S CRI P TI ON
. ':;cpr
PAY LAST
BALANCE
.AMOUN T
LABORATORY
SUMMARY OF CHARGES
LABORATORY
TOTAL CHARGES
BALANCE
12.000
38.440
45.680
93 .880
44.000
47.500
DEPT TOTAL
12.00
38 .44
45 .68
93 .88
44.00
47.50
281.50
281.50
281.50
281.50
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
z 1 1 niyiit'dnv we oac uiry,
NO.
04
05
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: P OLI C Y N U M B E R
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G U A R A NTOR
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710 SOUTH 9TH S TR E E T
S A C C I TY I A 50583
P OLI C Y HO LDE R ""^
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04/22/13
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E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
D O C T O R " Lorin# Hospital
GYAJSIO , B. K. . x-N^
V _ o
BILLING D AT E |\/\" ~ \ E NO. E X T E NS I ON
712-297-0460
' MED . R EC . NO . /AD MISSIO NNO .
06/05/13 PAGE 1 21 1 Highland Ave Sac City, I A 50583 ( 22756 / 556988
NO .
04
05
I NSUR ANC E C O MPANY PO LI C Y NU MBER
NAT IO NWID E SPEC HEALT H C LF00812823
SELF-PAY 481131762
GUAR ANT O R
JUST INA BUSC HMANN
710 SO UT H 9T H ST
SAC C IT Y IA 50583
PO LIC Y HO LD ER PLAN
BUSC HMANN, JUST
BUSC HMANN, JUST
PAT IENT NAME ' MED . R EC . NO . /AD MISSIO NNO .
JUST INA BUSC HMANN 22756 / 556988
PAT IENT
T YPE
23
AD MI SSI O ND AT E
05/30/13
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05/30/13 <fc/flBi/84 M 29
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E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
Ui/U-Tl t.\>1 T
2:39:26 pm
MR# / Adm #: 15869 / 560165
Guarantor #: 22756
Doctor#: 215
Ins Codes: 05
Demand Bid From History
LORING HOSPITAL
211 HIGHLAND AVE
SAC CITY, IA 50583
712-662-7105
BUSCHMANN, TAYLOR J
BUSCHMANN, JUSTIN A
BLESSINGTON, KAY
Bed#: Patient Type: 20
Page:
Admission Date:
Discharge Date:
Patient Age:
DRG#:
08/12/2013
08/12/2013
25
LOS: 0
Charge Date Date Ent Date Pst Charge # Description Rev Cpt Qty Unit Price Charge Amt
08/12/13
08/12/13
08/12/13
08/12/13
08/12/13
08/12/13
08/15/13
08/15/13
08/15/13
LABORATORY
18.00
44.00
113.00
Dept Total
18.00
44.00
113.00
175.00
Patient Total
Payments Received
175.00
0.00
Balance Due
175.00
A,R_Demand_BI!l_History.rpt
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L. F. NOLL, INC.
PLAINTIFF
VS
JUSTIN A. BUSCHMANN
TAYLOR J. BUSCHMANN
DEFENDANT(S)
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
NO.
For Defendant: TAYLOR J. BUSCHMANN
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 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 $1161.90 is the balance due and owing as of MAY 27, 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, TAYLOR J. BUSCHMANN. resides at 710 S 9TH ST SAC CITY IA 50583-
2236, is employed at BOMGAARS 3141 255TH 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, 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.do.
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. 0 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.^NOLL, VIC'E PRESIDENT
705 Douglas St., Suite 344
Sioux City, IA 51101
712-252-0583
0002810456
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
NOTICE OF RIGHT TO CURE DEFAULT
NCS, INC DS&
MOLL COLLECTION SERVICE
705 DOUGLAS STREET, SUITE 344
PO BOX 593
SIOUX CITY IA 51102-0593
{712)252-0583
APRIL 24, 2014
JUSTIN A BUSCHMANN
TAYLOR J BUSCHMANN
710 S 9 ST
SAC CITY IA 50583-2236
(LISTED BELOW IF MORE. THAN ONE)
TOTAL AMOUNT DUE: $1161.90 - . , , . : . . .
AMOUNT IN DEFAULT: $1161.90 . - ...
You are now in default on this credit transaction. You have a right to
correct this default within 20 days. If you do so, you may continue with1 the
contract as though you did not default... . . ,, . . . . . . , -
YOUR DEFAULT CONSISTS1 OF:
Correct this default by:
FAILURE TO PAY AS AGREED
Paying the amount in default, $1161.90 to
Noll Collection Service, agent for the above, .
creditor.
If you do not correct this default within 20 days, we may, exercise 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..
0002810456
Client Name Client Ref No Principal Intqresl Other Total
LORING
LORING
LORING
LORING
LORING
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
538605
554219
555406
556988
560165
30'.
331.
173..
426.
175.
88
94
67
11
00
8
3
7
4
.49-- .-
.09 ' ' '
.26 -
.76 ., .
.70. , .
' .00
.00
.00
.00
.00
31.
340.
176.
433.
179.
37
03
93
87
70
1,161.90
E-FILED 2014 MAY 30 4:12 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: APRIL 23, 2014
LORING HOSPITAL 014345
ATTN JAN WISEMAN
211 HIGHLAND AVE
SAC CITY IA 50583
ATTENTION:
RE: JUSTIN A BUSCHMANN
538605 $1^3.7.60 08/27/12
The above debtor refuses to cooperate. We recommend further action, in
order to enforce collection. Before our attorney ca^^r-oceed, 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
JUSTIN A BUSCHMANN
TAYLOR J BUSCHMANN
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $1137.60 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 prr day of
LORING HOSPITAL
By:
A
(Name and Official Title)
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
0002914261
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
D O C T O R " ' Lorin^ Hospital
PEK, Z. L. f^~?
B I LLI N G D AT E ' |\/{"
T ELEPHO N E N O . EXT EN S I O N
712-661-9590
MED , R EC . N O . / AD MI S S I O N N O .
04/02/13 PAG E 1 J 211 Highland Ave -Sac City, i A 50583 22756 / 554219
N O .
04
05
I N SUR AN C E C O MPAN Y PO LI C Y N UMB ER
N AT I O N WI D E SPEC HEALT H C LF00812823
SELF-PAY 481131762
G UAR AN T O R
JUST IN A B USC HMAN N
710 SO UT H 9T H ST R EET
SAC C I T Y I A 50583
PO LI C Y HO LD ER " PLAN
B USC HMAN N , JUST
B USC HMAN N , JUST
PAT I EN T N AME MED . R EC . N O . / A D MI S S I O N N O ,
JUST I N A B USC HMAN N 227S6 / 554219
PAT I EN T
T YPE
20
AD MI S S I O N D AT E
03/27/13
D I S C HAR G E D AT E B I R T HD AT E SEX AG E
03/27/13 lB /a/84 M 28
G UAR AN T O R I S R ES PO N S I B LEFO R AN Y AMO UN T S D UE-AFT ER T HEI N S UR AN C E C O MPAN I ES MAKE T HEI R PAYMEN T S ^^H^FWri^^^l
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T O T AL C HAR G ES
B ALAN C E

1
QUAN T I T Y
1
1
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C HAR G E
18.000
85. 000
93.880
44. 000
91.000
151.130
115.380
50. 700
38. 850
331.88
406.06
737. 94
C FT
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E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
MARCZEWSKI, L. J.
BILLING DATE
04/05/12 PAGE
Loring" Hospital
^; TELEP HON. E- NO- . . . EX TENS ION
211 Highland Ave- Sac City, IA 50583
712-661-9530
; WEDi'- REG; . NQ; - /'- AD'MlS S |ON- NO.
2275S / 53S 60S
INS URANCE COMP ANY P OLICY NUMBER' ". iP O'LICY HOtDER PLAN
NATIONWIDE SPEC HEALTH
SELF-PAY
QLF00812823
4S1131762
BUS CHMANN, JUST
BUSCHMANN, JUST
UARANTOR
P ATIENTNAME
,MED,-REC-. N0.7ADMIS S ION NO.
JUSTIN A BUSCHMANN
710 SOUTH 9TH STREET
SAC CITY IA 50583
JUSTIN A BUSCHMAHN 22756 / 538605
P ATIENT
'TYP E'
20
ADMIS S ION DATE
03/30/12
DIS CKARGE- 'DATE
03/30/12
BIRTH DATE'
UARANTOR [S RES P ONS IBLE FOR ANY - AMOUNTS : DUr AFTER TJ4EJNS UR^^
DATE-
CHARGE
- CODE-
UANTITY
S EX
M
AGE
27
PAY LAST
BALANCE
. AMOUNT
3-30
3-30
3-30
3-30
03-30
03-30
12 .000
38.440
45.680
93 .880
44.000
47.500
LABORATORY DEPT TOTAL
12.00
38.44
45. 68
93 .88
44.00
47 .50
281.50
SUMMARY OF CHARGES
LABORATORY
TOTAL CHARGES
BALANCE
231.50
281.50
281. 50
3
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
^ u*
NO.
04
05
INSURANCE COMPANY
NATIONWIDE SPEC HEALTHC
SELF-PAY
5)^ )~~}
4 1 i myni 'di lu rtvu oao
; POLICY NUMBER
L.F00312823
481131762
GUARANTOR
JUSTIN A BUSCHMANN
710 SOUTH 9TH STREET
SAC CITY IA S0583
O/fy. t/\ \ / ^DD^uo i
POLICY HOLDER ^ ^ PLAN
BUSCHMANN, JUST
BUSCHMANN, JUST
PATIENT NAME MED. R-EC. NO. / ADMISSION NO.
JUSTIN A BUSCHMANN- 2275S / 555406
'PATIENT
TYPE
22
ADMISSION DATE
04/22/13
DISCHARGE DATE BlRTHDATE SEX AGE
04/22/13 **'lfc?-=M 29
GUARANTORS RESPONSIBLE FOR'ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS ^ ^ WftF^ Tt^ ^ ^ l
DATE
04-22
1
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. DESCRIPTION
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RADIOLOGY, TECH
SUMMARY OF CHARGES
RADIOLOGY, TECH
TOTAL CHARGES
BALANCE
]$^-3^<
i
\Y
1
CHARGE
135 . 000
135.00
135. 00
7j 3> w 7'
CPT
DEPT TOTAL
/Cy^ P ^{
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V^ -''
y^
/
AMOUNT
135.00
135. 00
*-
~ j ^ f vC"
-25^ icTi\^ \^ X-
135. 00
/
~l
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
D O C T O R ' . Loring- Hospital
GYANO , B . K .
St^A
T ELEP HO NE NO . EXT ENSI O N
v^,0 ' 712-297-0460
v^vi
B-I LLI NG D AT E ' |\ \/^ /\
.
M&D . R EC . NO . /AD MISSIO N NO .
05/05/13 PAGE 1 J 211 Highland Ave Sac City, !A 50583 [ 22756
NO ,
04
05
I NS U R ANC E C O MP ANY ' PO LIC Y NU MBER
NAT IO NWID E SPEC HEALT H C LF00812823
SELF-PAY 481131762
. GUAR ANT O R
JUST IN A BUSC HMANN
710 SO UT H 9T H ST
SAC C IT Y IA 50583
PO LIC Y HO LD E R ' PLAN
BUSC HMANN; JUST
BUS C HMANN , JUS T
PAT IENT NAME '
/556988
MED . R EC . NO . /AD MISSIO N NO .
JUST IN A BUSC HMANN 22756 / 556988
PAT IENT
T YPE
23
AD MISSIO N D AT E
05/30/13
D ISC HAR GE D AT E BIR T HD AT E SEX AGE
05/30/13 VV)/84 M 29
GU AR ANT O R IS R ESP O NSI BLE FO R ANY AMO U NT S D UE AFT ER T HE I NS U R ANC E C O MP ANI E S MAKE T HEI R PAYMENT S ^^KT T rT T O ^^^B
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05- 30
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BALANC E
- O _
^
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QUANT IT Y
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132 .110
294. 000
132. 11
294. 00
426.11
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E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
2:39:26 pm
MR#/Adm#:
Guarantor #:
Doctor #:
Ins Codes:
15869/560165
22756
215
05 Bed#:
^ Demand Bill From History
LORING HOSPITAL
211 HIGHLAND AVE
SAC CITY, IA 50583
712-662-7105
BUSCHMANN, TAYLOR J
BUSCHMANN, JUSTIN A
BLESSINGTON, KAY
Patient Type: 20
Page:
Charge Date Date Ent Date Pst Charge # Description
Admission Date: OS/12/2013
Discharge Date; 08/12/2013
Patient Age: 25
DRG#: LOS: 0
Rev Cpt Qty Unit Price Charge Amt
08/12/13
08/12/13
08/12/13
08/12/13
08/12/13
08/12/13
08/15/13
08/15/13
08/15/13
18.00
44.00
113.00
LABORATORY Dept Total
18.00
44.00
113.00
175.00
Patient Total
Payments Received
175,00
0,00
Balance Due 175.00
R_Demand__BIll_History.rpt
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
E-FILED 2014 JUN 27 10:50 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 SCSC015449

vs.
JUDGMENT ENTRY
Defendant(s),


JUSTIN A BUSCHMANN
710 S 9TH ST
SAC CITY IA 50583
TAYLOR J BUSCHMAN
710 S 9TH STREET
SAC CITY IA 50583



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 defendants,
jointly and severally, in the amount of $ 1137.60 with interest at the rate of 2.10 % from the 30th day
of May, 2014 and court costs.

The Court further enters judgment for prejudgment interest in the amount of $24.30.




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: $1200.00
1 of 2
E-FILED 2014 JUL 01 1:54 PM SAC - CLERK OF DISTRICT COURT
State of Iowa Courts
Case Number Case Title
SCSC015449 L F NOLL INC VS BUSHMANN JUSTIN A AND TAYLOR J
Type: ORDER FOR JUDGMENT
So Ordered
Electronically signed on 2014-07-01 13:54:44
2 of 2
E-FILED 2014 JUL 01 1:54 PM SAC - CLERK OF DISTRICT COURT