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
JERRY L. RAHN
515 PLATTST
SAC CITY IA 50583
AMY L. RAHN FKA AMY GERRY
515 PLATTST
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 $5191.74. 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
$5000.00
INTEREST
$191.74
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^) 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 Plaintlff(s).
6. You must also notify the clerk's office of any address change.
E-FILED 2014 JUN 13 2:56 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
0001875723
JUNE 9, 2014
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L. F. NOLL, INC
PLAINTIFF
VS
JERRY L. RAHN
AMY L. RAHN FKA AMY GERRY
DEFENDANT(S)
VERIFICATION OF ACCOUNT
I DENTI FI CATI ON OF JUDGMENT
DEBTOR AND CERTI FI CATE RE
MILITARY SERVICE
NO.
For Defendant: AMY L. RAHN FKA AMY GERRY
1. I, T. L. Noll, Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose ciaim(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 $5191.74 is the balance due and owing as of JUNE 9, 2014 from Defendant(s) to Plaintiff(s) and any interest
amount owing is accurately stated in the Petition and Original Notice.
2. ! further state that Defendant, AMY L. RAHN FKA AMY GERRY, resides at 515 PLATT ST SAC CITY lA
50583, is employed at STEWART MEMORIAL COMMUNITY HOS 1301 WMAIN ST LAKE CiTY IA 51449.
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
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
OR
service of the United States government.
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. NOLL, VICE PRESIDENT'
705 Douglas St., Suite 344
Sioux City, 1A51101
712-252-0583
0001875723
E-FILED 2014 JUN 13 2:56 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
FEBRUARY 25, 2014
JERRY L RAHN
AMY RAHN
515 PLATT ST
SAC CITY IA 50583
RE: (LISTED BELOW IF MORE THAN ONE)
TOTAL AMOUNT DUE: $5876.36
AMOUNT IN DEFAULT: $5876.36
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 did not default. . . . .
YOUR DEFAULT CONSISTS OF:
Correct this default by:
FAILURE TO PAY AS AGREED
Paying the amount in default, $5876.36 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.
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY AND ALL INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
0001875723
Client Name Client Ref No Principal Interest Other Total
LORING
LORING
LORING
LORING
LORING
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
50855
50855
50855
493712
493713
1,
2,
239.
94.
94.
671.
933.
21
00
00
78
36
3.
1.
.
64.
11.3.
37
09
82
81
72
.00
.00
.00
.00
.00
1,
3,
242.
95.
94.
736.
047.
58
09
82'
59
08
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
Client Name Client Ref No Principal Interest -Other -Total
LORING HOSPITAL 558955 646.99 13.21 , .00 660.20
5,876.36
E-FILED 2014 JUN 13 2:56 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: FEBRUARY 24, 2014
LORING HOSPITAL 014345
ATTN JAN WISEMAN
211 HIGHLAND AVE
SAC CITY IA 50583
ATTENTION:
RE: JERRY L RAHN
GERRY, J-M L 558955 $5679.34 01/14/14
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
JERRY L RAHN
AMY RAHN
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $5679.34 lawful interest
thereon; and does hereby authorize said assignee to do and perform all acts
necessary for collection; commencement of suit in the name of the assignee,
settlement, adjustment, compromise or satisfaction of said claim. Assignor
hereby certifies that said claim is justly due and owing and warrants
compliance with requirements of the Iowa Consumer Credit Code as well as
disclosure and other provisions of truth in lending, and that same is free of
set-offs and other defenses.
Dated this < * t f > day of
LORING HOSPITAL ' U
By: Qf t xi, \j^^kL!C^Q-r+^*&uJ$^^
( J , Name"and Official Title) ^" ^
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
0002949661
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
L o r i n ^ r Ho spi tal
BL ESSINGTON, KAY
BILLING DATE
08/21/09 PAGE 1
o--. >^p
211 Highland Ave Sac City, !A 50583
f
TELEPHONE NO.
712-662-0131
\N
MED. REC. NO. / ADMISSION NO.
9501 / 493712
NO
INSURANCE COMPANY POLICY NUMBER POLICY HOLDER PLAN
05 SEL F-PAY
481803956 RAHN, JERRY L
GUARANTOR
PATIENT NAME MED. REC. NO. / ADMISSION NO,
JERRY L RAHN
202 S 13TH STREET
SAC CITY IA 50583
JERRY It RAHN 9601 / 493712
PATIENT
TYPE
11
ADMISSION DATE
08/10/09
DISCHARGE DATE
08/10/09
BIRTHDATE SEX
M
AGE
39
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
CHARGE
CODE
DESCRIPTION QUANTITY CHARGE CRT
PAY LAST
BALANCE
AMOUNT
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
EMERGENCY ROOM
LABORATORY
PHARMACY
RADIOLOGY, PROFESS
RADIOLOGY, TECH
MEDICAL SUPPLIES
IV SOLUTIONS
711.000
102.000
12. 000
36.240
36.400
64.520
45.680
44.000
55.000
47 .500
38 .480
69.000
2. 650
5. 020
87.830
47.630
135.000
7 .620
4.380
8 .000
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
711.00
102.00
813.00
12.00
36.24
36.40
64.52
45.68
44.00
55.00
47 .50
38.48
373.82
69.00
69 .00
2.65
5 .02
175.66
183 .33
47 .63
47 . 63
135.00
135.00
7 .62
4.38
12.00
32. 00
32.00
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
D O C T O R ( Loring- Hospital
BLESSINGT O N, KAY Q V^
BILLINGD AT E |\
"f^|?''
08/21/09 PAGE 2 ^ 27 7 Highland Ave Sac City, IA 50583
T ELEPHO NENO . EXT ENSIO N
7 12-662-0131
MED . R EC ,NO . / AD MISSIO NNO .
9601 / 4937 12
NO . INSUR ANC E C O MPANY PO LIC YNUMBER PO LIC YHO LD ER PLAN
05 SELF-PAY 481803956 R AHN, JER R YL
GUAR ANT O R PAT IENT NAME MED . R EC . NO . / AD MISSIO NNO .
JER R YL R AHN JER R YL R AHN 9601 / 4937 12
202 S 13T H ST R EET ?TYPE^ AD MISSIO ND AT E D ISC HAR GE D AT E BIR T HD AT E SEX AGE
SAC C IT YIA 50583 11 08/10/09 08/10/09 0T/H/1Q M 39
GUAR ANT O R ISR ESPO NSIBLEFO R ANYAMO UNT S D UEAFT ER T HEINSUR ANC EC O MPANIESMAKET HEIR PAYMENT S
D AT E
C HAR GE
C O D E
D ESC R IPT IO N
SUMMAR YO F C HAR GES
EMER GENC Y R O O M
LABO R AT O R Y
EKG
PHAR MAC Y
R AD IO LO GY, PR O FESSIO NAL
R AD IO LO GY, T EC H
MED IC AL SUPPLIES
IVSO LUT IO NS
T O T AL C HAR GES
BALANC E
QUANT IT Y C HAR GE
813. 00
37 9. 82
69. 00
183.33
47 . 63
135.00
12 .00
32. 00
157 1.7 8
C PT
PAYLAST 1
BALANC E 1
AMO UNT
167 1.7 8
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
Lorin^ Hospita]
MILLER, RODNEY
B I LLI N G DATE
09/11/09 PAGE
O-. ^-x.O
211 Highland Ave-Sac City, !A 50583
TELEPHONE NO.
712-662-0131
EXTENSION
MED. REG. NO. / ADMISSION NO.
9601 / 493713
NO POLICY NUMBER POLICY HOLDER PLAN
05 SELF-PAY 481803956 RAHN, JERRY L
GUARANTOR PATIENT NAME MED. REC. NO. / ADMISSION NO.
JERRY L RAHN
515 PLATT STREET
SAC CITY IA 50583
JERRY L RAHN
9601 / 493713
PATIENT
TYPE
13
ADMISSION DATE
08/10/09
DISCHARGE DATE
08/12/09
BiRTHDATE
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
CHARGE
CODE
DESCRIPTION QUANTITY CHARGE CPT
SEX
M
AGE
39
PAY LAST
BALANCE
AMOUNT
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-12
08-11
08-11
08-11
OBSERVATION ROOM
LABORATORY
REFERRAL LABORATOR
EKG
495,840
12.000
12.000
12 .000
3S.400
36.400
36.400
64.520
64.520
64.520
45.680
17.720
81.120
55 .000
55 .000
55 .000
14.200
16.250
69.000
69.000
4.780
126.900
3 .130
3.130
2.650
2.650
14.250
279.240
279.240
87.830
57.500
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
PHARMACY
DEPT TOTAL
991.68
991.68
12. 00
12.00
12 .00
36.40
36.40
36.40
64.52
S4.52
64 .52
45.68
17.72
81.12
55. 00
55.00
55.00
14.20
662.48
16.25
16.25
69. 00
69.00
138 .00
9.56
126 .90
6.26
6.26
2,65
5.30
14.25
279.24
279.24
87.83
230 .00
1047.49
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
D O C T O R Lorintf Hospital ' T E LE P HO N E N O , E X T E N S I O N
MI LLE R , R O D N E Y y"~N ^> Q 712-662-0131
B I L L I N G D AT E ]\V A ME D . R E C . N O . /AD MI S S I O N N O ,
09/11/09 P AG E 2 J 211 Highland Ave Sac City, !A 50583 9601/ 493713
N O . I N S U R A N C E C O MP A N Y P O LI C Y N U MB E R P O LI C Y HO LD E R P LAN
05 S E LF-P AY 481803956 R AHN , JE R R Y L
G UAR AN T O R P AT I E N T N A ME ME D . R E C . N O . / A D MI S S I O N N O .
JE R R Y L R AHN JE R R Y L R AHN 9601/ 493713
pA T f P MT
515 P LAT T S T R E E T T YP E AD MI S S I O N D AT E D I S C HA R G E D AT E B I R T HD AT E S E X AG E
S AC C I T Y I A 50583 13 08/10/09 08/12/09 *?/*/70 M 39
G U A R A N T O R I S R E S P O N S I B LE FO R AN Y A MO U N T S D UE AFT E R T HE I N S U R A N C E C O MP A N I E S MA K E T HE tR P AYME N T S
D AT E
08-10
08-11
08-10
08-10
08-10

C HA R G E
C O D E
4B3S ^BI
dB HB T
B^O S V
" HWP fflflP
^uitaft
D E S C R I P T I O N
UHMB MMB M0R O B S E M
$S MHMBMMn
^ WMHWMffiS V
*aattuun*aa&(^fffgpaMpBOf
ME D I C AL S UP P LI E S
JUMUMJiUllJ U I J U I I I L 1
I V S O LUT I O N S
S UMMAR Y O F C HAR G E S
O B S E R VAT I O N R O O M
LAB O R AT O R Y
R E FE R R AL LAB O R AT O R Y
E KG
P HAR MAC Y
ME D I C AL S UP P LI E S
I V S O LUT I O N S
T O T AL C HAR G E S
B ALAN C E
QUAN T I T Y
1
1
1
1
3
C HA R G E
5. 200
1. 800
16. 460
30. 000
8. 000
991. 68
662. 48
16. 25
138. 00
1047. 49
53. 46
24. 00
2933. 36
C P T
D E P T T O T AL
D E P T T O T AL
P AY LAS T
B ALAN C E
AMO UN T
5. 20
1. 80
16. 46
53. 46
24. 00
24. 00
2933. 36
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
spital
LANKFORD, TONYA
BILLING DATE
07/23/13 PAGE 211 Highland Ave Sac City, !A 50583
r -
TELEPHONE NO.
712-651-8342
EXTENSION
. MED. REC. NO. 7ADMISSION'NO.
20253 / 558955
NO. INSURANCE COMPANY ' POLICY ' NUMBER ' . , . - ' ' . ; POLlC' Y' HO' LDER ' - PLAN . ,
04 BAAI ABC 20Q41LA4605A RAHN, JERRY L
05 SELF- PAY 484252683 GERRY, Lft L ^_ <^
GUARANTOR , ' . - ' . ' . ' ' ' PATIENT NAME . "O ' ' - ' / MED. REC. NO. / ADMI S S I ON NO.
JERRY L RAHN LJK L GERRY 20253 / 558955
PATIFNT
515 PLATT STREET TYPE ADMI SSI ON DATE DtSCHARGE. DATE . B I RTHDATE SEX AGE
SAC CITY IA 50583 11 07/15/13 07/15/13 ^/l^/96 F 16
GUARANTOR IS RESPONSI B LE FOR. ANY AMOUNTS ' DUE. AFTER THE I NSURANCE COMPANI ES ' MAKETH EJR PAYMENTS . - - , , ^^H^fTFWay^^H
DATE
07-15
07- 15
07- 15
07- 15
07-15
CHARGE
- CODE
^^^^^^^fli
l^^HHBV*
anmB*-
, mm in
||, I H I B I
jiuiujm
^f
. DESCRI PTI ON' '
WflBVnHHVnKMVfe
EMERGENCY ROOM
am mmniHiiiii MI I I
PHARMACY
BfiBSBMMHHBOfe
RADIOLOGY, PROFESS
WMHH^HHHm
RADIOLOGY, TECH
SUMMARY OF CHARGES
EMERGENCY ROOM
PHARMACY
RADIOLOGY, PROFESSIONAL
RADIOLOGY, TECH
TOTAL CHARGES
BALANCE
iS. Sti
QUANTITY
1
1
1
1
1
^
. CHARGE. - .
405. 000
183. 620
82. 990
40. 603
148 . 500
588 . 62
82. 99
40. 60
148 . 50
860. 71
r\CPT
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
^pdl
( LA
AMOUNT
405. 00
183. 62
588 . 62
82. 99
82. 99
40. 60'
40. 60
148 . 50
148 . 50
860. 71
- O -
\n-&
1
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L F. NOLL, INC
PLAINTIFF
VS
JERRY L. RAHN
AMY L. RAHN FKA AMY GERRY
DEFENDANT(S)
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
NO.
For Defendant: JERRY L. RAHN
1. I, T. L. Noll, Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose clairn(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 $5191.74 is the balance due and owing as of JUNE 9, 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, JERRY L. RAHN, resides at 515 PLATT ST SAC CITY !A 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.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.
L.F. NOLL, INC.
T. L MOLL, VICE PRESIDENT
705 Douglas St., Suite 344
Sioux City, IA51101
712-252-0583
0001875723
E-FILED 2014 JUN 13 2:56 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
FEBRUARY 25, 2014
JERRY L RAHN
AMY RAHN
515 PLATT ST
SAC CITY IA 50583
RE: (LISTED BELOW IF MORE THAN ONE)
TOTAL AMOUNT DUE: $5876.36
AMOUNT IN DEFAULT: $5876.36
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 did not default. . . . .
YOUR DEFAULT CONSISTS OF:
Correct this default by:
FAILURE TO PAY AS AGREED
Paying the amount in default, $5876.36 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.
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY AND ALL INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
0001875723
Client Name Client Ref No Principal Interest Other Total
LORING
LORING
LORING
LORING
LORING
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
50855
50855
50855
493712
493713
239
94
94
1,671
2,933
.21
.00
.00
.78
,36
3.
1.
.
64.
113.
37
09
82
81
72
.00
.00
.00
.00
.00
242.
95.
94.
1,736.
3,047-
58
09
82-
59
08
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
Client Name Client Ref No Principal Interest Other -Total
LORING HOSPITAL 558955 646.99 13.21 . .00 660.20
5,876.36
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
NCS, ING DBA
NOLL COLLECTION SERVICE
"A Professional Debt Collection Service Since 1965"
705 DOUGLAS STREET, SUITE 344
SIOUX CITY, IA 51101
(712) 252-0583
DATE: FEBRUARY 24, 2014
LORING HOSPITAL 01434S
ATTN JAN WISEMAN
211 HIGHLAND AVE
SAC CITY IA 50S83
ATTENTION:
RE: JERRY L RAHN
GERRY, !*m L 558955 $5679.34 01/14/14
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
JERRY L RAHN
AMY RAHN
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $5679.34 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 c*Co day of 4^J?yuxc uK^j^ , s o l 1 - ^- .
HOSPITAL ' (}~
BY:Qft* i. \j^\ltf*a-rr**-*yijJbJLSFSL^
[Name and Official Title)^U
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
0002949661
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
D O C T O R
Loring* Hospital
BL ESSINGTON, KAY
BILLING DATE
08/21/09 PAGE 1
o-. ,*p
211 Highland Ave Sac City, IA 50583
TELEPHONE NO.
712-562-0131
EXTENSION
MED. REC. NO. / ADMISSION NO.
9601 / 493712
NO, INSUR ANC E C O MPANY POLICY NUMBER POLICY HOLDER PLAN
O S SELF-PAY 481803956 RAHN, JERRY L
GUAR ANT O R PATIENT NAME MED. R EC . NO. / AD MISSIO N NO,
JERRY L RAHN
202 S 13TH STREET
SAC CITY IA 50583
JERRY L RAHN 9601 / 493712
PATIENT
TYPE
11
ADMISSION DATE
08/10/09
DISCHARGE DATE
08/10/09
BIRTHDATE
i/W/70
SEX
M
AGE
39
GU AR ANT O R IS RESPONSIBLE F OR ANY AMOUNTS DUE AF TER THE INSURANCE C O MP ANIES MAK E THEIR PAYMENTS
DATE
C HAR GE
C O D E
D ESCRIPTION QUANTITY CHARG- E CPT
PAY LAST
BALANCE
AMOUNT
08-10
08-10
08-10
08-10
08-10
08-10
08-10
03-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
08-10
EMERGENCY ROOM
LABORATORY
PHARMACY
RADIOLOGY, PROFESS
RADIOLOGY, TECH
MEDICAL SUPPLIES
IV SOLUTIONS
711.000
102.000
12.000
36.240
36.400
64.520
45.680
44.000
55.000
47 .500
38.480
69.000
2.650
5.020
87.830
47.630
135.000
7.620
4.380
8.000
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
711.00
102 .00
813.00
12 .00
36.24
36.40
64.52
45.68
44 .00
55 .00
47.50
38.48
379.82
69.00
69.00
2 .65
5.02
175.66
183.33
47. 63
47 . 63
135.00
135 . 00
7 .62
4.38
12 .00
32.00
32 .00
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
D O C T O R Lorin^ Hospital
BLESSINGT O N, KAY o /-v
BILLINGD AT E |\
~>
^
08/21/03 PAGE 2 J 21 1 Highland Ave Sac City, !A 50583
T ELEPHO NENO . EXT ENSIO N
712-662-0131
MED . R EC . NO . /AD MISSIO NNO .
9601 / 493712
NO . INSUR ANC EC O MPANY PO LIC YNUMBER PO LIC YHO LD ER PLAN
05 SELF-PAY 481803956 R AHN, JER R YL
GUAR ANT O R PAT IENT NAME MED . R EC . NO . /AD MISSIO NNO .
JER R YL R AHN JER R YL R AHN 9601 / 493712
PAT 1FNT
202 S 13 T H ST R EET T YPE AD MISSIO ND AT E D ISC HAR GED AT E B1R T HD AT E SEX AGE
. SAC C IT YIA 50583 11 08/10/09 08/10/09 ^-/*/7QM 39
GUAR ANT O R ISR ESPO NSIBLEFO R ANYAMO UNT S D UEAFT ER T HEINSUR ANC EC O MPANIES MAKET HEIR PAYMENT S
D AT E
C HAR GE
C O D E
D ESC R IPT IO N
SUMMAR YO F C HAR GES
EMER GENC YR O O M
LABO R AT O R Y
EKG
PHAR MAC Y
R AD IO LO GY, PR O FESSIO NAL
R AD IO LO GY, T EC H
MED IC AL SUPPLIES
IV SO LUT IO NS
T O T AL C HAR GES
BALANC E
QUANT IT Y C HAR GE
813 .00
379 . 82
69. 00
183.33
47. 63
135. 00
12.00
32. 00
1671.78
O PT
PAYLAST
BALANC E
AMO UNT
1671.78
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
p i t a l
MILLER; RODNEY
BILLING DATE
09/11/09 PAGE 1
O--K^-J3
211 Highland Ave -Sac City, !A 50583
TELEPHONE NO.
712-662-0131
EXTENSION
MED. REG. NO. / ADMISSION NO.
9601 / 493713
N O , INSURANCE COMPA'NY POLICY NUMBER POLICY HOLDER PLAN
05 SELF-PAY 481803956 RAHN, JERRY L
GUARANTOR PATIENT NAME MED. REC. NO. / ADMISSION NO,
JERRY L RAHN
515 PLATT STREET
SAC CITY IA 50583
JERRY L RAHN 9601 / 493713
PATIENT
TYPE
13
ADMISSION DATE
08/10/09
DISCHARGE DATE
08/12/09
BIRTHDATE
GUARANTOR IS RESPONSIBLE F OR ANY AMOUNTS DUE AF TER THE INSURANCE COMPANIES MAK E THEIR PAYMENTS
DATE
CHARGE
CODE
DESCRIPTION QUANTITY CHARGE CPT
SEX
M
AGE
39
PAY LAST
BALANCE
AMOUNT
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-11
08-11
08-12
08-12
08-11
08-11
08-11
OBSERVATION ROOM
LABORATORY
REFERRAL LABORATOR
EKG
495.840
12 .000
12.000
12.000
36.400
36.400
36.400
64.520
64.520
64.520
45.680
17.720
81.120
55.000
55 .000
55.000
14.200
16.250
69.000
69.000
4.780
126.900
3 .130
3 .130
2 .650
2 . 650
14.250
279.240
279.240
87.830
57.500
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
DEPT TOTAL
PHARMACY
DEPT TOTAL
991.68
991.68
12.00
12.00
12 .00
36.40
36.40
36.40
64.52
64.52
64 .52
45 .68
17.72
81.12
55.00
55.00
55.00
14.20
662.48
16.25
16.25
6S.OO
69.00
138.00
9.56
126.90
6.26
6.26
2.65
5 .30
14.25
279.24
279.24
87.83
230.00
1047 .49
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
DOCTOR
Lorin# Hospital
MILLER, RODNEY
BILLING DATE
09/11/09 PAGE
21 1 Highland Ave Sac City, IA 50583
[
TELEPHONE NO,
712-662-0131
EXTENSION
MED. REC. NO. / ADMISSION NO.
9601 / 493713
_ . . . , , . .
NO. INS U RANC E C OMPANY POLICY NU MBER POLICY HOLDER PLAN
05 S ELF-PAY 481803956 RAHN, JERRY L
GU ARANT OR PAT IENT NAME MED. REC . NO. / ADMIS S ION NO.
JERRY L RAHN JERRY L RAHN 9601 / 493713
53^ PLATT STREET ?T?P^ ADMIS S ION DATE DIS C HARGE DATE BIRT HDAT E S EX AGE
SAC CITY IA 50583 13 08/10/09 08/12/09 **/*/70M 39
GU ARANT OR IS RES PONS IBLE FOR ANY AMOU NT S DU E AFTER T HE INS U RANC E C OMPANIES MAK E T HEIR PAYMENT S
DATE
08-10
08-11
08-10
08-10
08-10
C HARGE
C ODE
tfEgSOl
4flHGH0
jpMBBpljffP
_jtIE
DES C RIPT ION
YBBHHHMHHHKSEM
-gma^BHMMEV
^^BHBWMHSSV
mnmnHME^RK
MEDICAL S UPPLIES
jmnmmwwm&Ku*
IV SOLUTIONS
SUMMARY OF CHARGES
OBS ERVATION ROOM
LABORATORY
REFERRAL LABORATORY
EKG
PHARMACY
MEDICAL S UPPLIES
IV SOLUTIONS
TOTAL CHARGES
BALANCE
QU ANT IT Y
1
1
1
1
3
C HARGE
5. 200
1. 800
16. 460
30. 000
8 . 000
991. 68
662 . 48
16.25
138. 00
1047. 49
53 .46
24 . 00
2933 . 36
CPT
DEPT TOTAL
DEPT TOTAL
PAY LAST 1
BALANCE 1
AMOU NT
5. 20
1.80
16.46
30. 00
53 .46
24 . 00
24. 00
2933. 36
E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT
' ' D O C T O R . 1 ~ ~ ' Lorin^ Hospital -
- LANKFO R D , T O NYA ' ?S^~
oT " i
B I LLI NG D AT E - ' . |\
*f 0
07/23/1 3 PAG E ' 1 211 Highland Ave - Sac C /fy, IA 50583
' T E LE PHO NE NO . E XT E NSI O N
71 2- 661 - 8342
M E D . R E C . NO . 7 AD M I SSI O N' NO .
20253 / 558955
N O . ' ' - I NSU R ANC E C O M PANY ' \ PO LI C Y NU M B E R . . / ...; . PO LI C Y "HO LD E R ' / PLAN' . . ,
04 B AA! AB C 20041 LA4605A R AHN, JE R R Y L
05 SE LF- PAY 484252683 G E R R Y, LR L ^ <f
G U AR ANT O R ' - ' " . ' ' . ' ; PAT I E NT NAM E . " ; *J. ' - V . . M E D . R E C . NO . / AD M I SSI O N NO .
JE R R Y L R AHN LJK L G E R R Y 20253 / 558955
51 5 PLAT T
PAT 1 FNT
ST R E E T ' T Y P E AD M I SSI O N D AT E D I SC HAR G E . D AT E . B I R T HD AT E SE X AG E
SAC C I T Y I A 50583 1 1 07/1 5/1 3 07/1 5/1 3 B /B fc/96 F 1 6
G U AR ANT O R I S R E SPO NSI B LE FO R . ANY AM O U NT S"D U E . AFT E R T HE I NSU R ANC E C O M PANI E S- M AKE T HE l R PAYM E NT S - .
D AT E
07- 1 5
07- 1 5
07- 1 5
07- 1 5
07- 1 5
C HAR G E
. C O D E
,_^^^^^^M^B
i^^HB B d
PB H^^^^*'
^ ^AfflR ^^F
^^^P^B i^^^^
jB aiaa^n
^
. . D E SC R I PT I O N , '
V flB B B B B HB HB SMHfc
E M E R G E NC Y R O O M
iiiiii^wininp mil
PHAR M AC Y
V O MaSSHHHMB nfe
R AD I O LO G Y, PR O FE SS
MHHMHMM^
R AD I O LO G Y, T E C H
SUM M AR Y O F C HAR G E S
E M E R G E NC Y R O O M
PHAR M AC Y
R AD I O LO G Y, PR O FE SSI O NAL
R AD I O LO G Y, T E C H
T O T AL C HAR G E S
B ALANC E
X
U ANT 1 T Y
1
1
1
1
1
L
C HAR G E . .
405. 000
1 83. 620
82. 990
40. 603
1 48. 500
588. 62
82 . 99
40. 60
1 48. 5 0
860. 71
L
. C PT
D E PT T O T AL
D E PT T O T AL
D E PT T O T AL
D E PT T O T AL
?
PAY LAST
B ALANC E I
AM O U NT
405. 00
1 33. 62
588. 62
82 . 99
82. 99
40. 60'
40. 60
1 48. 5 0
1 48. 50
860. 71
- O -

E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT

E-FILED 2014 JUL 24 11:00 AM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY


Plaintiff(s), SMALL CLAIMS DIVISION

LF NOLL, INC
705 DOUGLAS ST, STE 344
SIOUX CITY IA 51101

Case: 02811 SCSC015455

vs.
JUDGMENT ENTRY
Defendant(s),


JERRY LYNN RAHN
515 PLATT STREET
SAC CITY IA 50583-2202
AMY LYNN RAHN
515 PLATT
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 defendant
in the amount of $ 5,000.00 with interest at the rate of 2.10 % from the 13th day of June, 2014 and
court costs.





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: $5,200.00
1 of 2
E-FILED 2014 JUL 24 1:13 PM SAC - CLERK OF DISTRICT COURT
State of Iowa Courts
Case Number Case Title
SCSC015455 L F NOLL INC VS JERRY & AMY RAHN
Type: ORDER FOR JUDGMENT
So Ordered
Electronically signed on 2014-07-24 13:13:21
2 of 2
E-FILED 2014 JUL 24 1:13 PM SAC - CLERK OF DISTRICT COURT