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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
SHANE M. MANTHE
308 WILLIAMS ST
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 $754.29. 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
$733.39
PRE-FILING INTEREST
$20.90
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 APR 22 8:16 AM SAC - CLERK OF DISTRICT COURT
ISICA R. NOLL AT0008873
Douglas St., Ste 502
Sioux City lA 51101
Phone (712) 224-2675
Fax (712) 252-4497
jrn(g)decklaw.net
ATTORNEY FOR PLAINTIFF
0002818573
APRIL 16,2014
E-FILED 2014 APR 22 8:16 AM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY
SMALL CLAIMS DIVISION
L. F. NOLL, INC.
PLAINTIFF
VS
SHANE M. MANTHE
DEFENDANT(S)
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
NO.
For Defendant: SHANE M. MANTHE
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. ! further state that the sum
of $754.29 is the balance due and owing as of APRIL 16, 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, SHANE M. MANTHE. resides at 308 WILLIAMS ST SAC CITY IA 50583. is
employed at WALMART SUPERCENTER 1831 LAKE AVE STORM LAKE IA 50588, 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. 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.
1 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.
,L. NOLLVICE PRESIDENT
705 Douglas St., Suite 344
Sioux City, IA51101
712-252-0583
0002818573
E-FILED 2014 APR 22 8:16 AM 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
MARCH 18, 2014
SHANE MICHAEL MANTHE
308 WILLIAMS ST
SAC CITY IA 50583
RE: (LISTED BELOW IF MORE THAN ONE) '. . . '-
TOTAL AMOUNT DUE: $1269. 79 . . . - - . - .
AMOUNT IN DEFAULT: $1269. 79 '
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, $1269. 79 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. . . * r. -- -; ;
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 question's, 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.
0002818573
Client Name ' Client Ref No Principal Interest Other - Total
LORING
LORING
LORING
HOSPITAL
HOSPITAL
HOSPITAL
485909
458573
517502
173.
314.
733.
67
65
39
1.
' 25.
20.
88
30
90
. 00
. 00
. 00
175.
339.
754.
5'5
95
29
1,269. 79
E-FILED 2014 APR 22 8:16 AM 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: MARCH 17, 2014
LORING HOSPITAL 014345
ATTN JAN WISEMAN
211 HIGHLAND AVB
SAC CITY IA 50583
ATTENTION: '
RE: SHANE MICHAEL MANTHE
1%.*fi
485909 , $ia-21.71 05/13/09
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.
* cpy 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.
I
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
SHANE MICHAEL MANTHE
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of $1221.71 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 H^day of YY}(U\jcJh. , 20 1 4*
LORING HOSPITAL
{Name and Official Title)
THIS IS AN ATTEMPT TO COLLECT A DEBT,
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
0002816055
E-FILED 2014 APR 22 8:16 AM SAC - CLERK OF DISTRICT COURT
D O C T O R " ~ ~ LOiing Hospital T E L E P HO N E N O . E X T E N S I O N
MAR C ZE WS KI , L . J. Q ^ o _~ o ;^ 712-660-2142
B I L L I N G D AT E , j\ ME C X R E C ' N 0- / AD MI S S I O N N O .
01/07/11 P AG E 1 j 211 Highland Ave> Sac City, !'A:5QS83 13408 / 517502
N O . I N S U R AN C E C O MP AN Y P O L I C Y N U MB E R P O L I C Y HO L D E R P L AN
05 S E L F-P AY 485987309 MAN T HE , S HAN E M
G U AR AN T O R P AT I E N T N AME ME D . R E C . N O . / AD MI S S I O N N O ,
S HAN E M MAN T HE S HAN E M MAN T HE 13408 / 517502
308 WI L L I AMS S T R E E T T YP E AD MI S S I O N D AT E D I S C HAR 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 11 01/01/11 01/01/11 / 78 M 32
G UAR AN T O R I S R E S P O N S I B L E FO R AN Y AMO UN T S D UE AFT E R T HE I N S U R AN C E C O MP AN I E S MAKE T HE I R P AYME N T S ^ ^ H^ T T ffT fT C n^ ^ ^ l
D AT E
01-01
01-01
01-01
01-01
01-01
01-01

C HAR G E
C O D E
D E S C R I P T I O N
E ME R G E N C Y R O O M
I N FUS I O N /C HE MO T HE
P HAR MAC Y
R AD I O L O G Y, P R O FE S S
'
R AD I O L O G Y, T E C H
S UMMAR Y O F C HAR G E S
E ME R G E N C Y R O O M
I N FUS I O N /C HE MO T HE R AP Y
P HAR MAC Y
R AD I O L O G Y, P R O FE S S I O N AL
R AD I O L O G Y, T E C H
T O T AL C HAR G E S
B AL AN C E
QUAN T I T Y
1
1
2
1
1
1
C HAR G E
405. 000
S I . 000
4. 510
94. 700
38. 670
135. 000
405. 00
51. 00
103. 72
38. 67
135. 00
733. 39
C R 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
D E P T T O T AL
D E P T T O T AL
AMO U N T
405. 00
405. 00
51. 00
51. 00
9. 02
94. 70
103. 72
38. 67
38. 67
135. 00
135. 00
733. 39
E-FILED 2014 APR 22 8:16 AM SAC - CLERK OF DISTRICT COURT
E-FILED 2014 MAY 12 10:58 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 SCSC015432

vs.
JUDGMENT ENTRY
Defendant(s),


SHANE MICHAEL MANTHE
308 WILLIAMS ST
SAC CITY IA 50583



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 in
the amount of $ 733.39 with interest at the rate of 2.11 % from the 22nd day of April, 2014 and court
costs.

The Court further enters judgment for prejudgment interest in the amount of $20.90.




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: $800.00
1 of 2
E-FILED 2014 MAY 15 3:26 PM SAC - CLERK OF DISTRICT COURT
State of Iowa Courts
Case Number Case Title
SCSC015432 L F NOLL IN VS SHANE M MANTHE
Type: ORDER FOR JUDGMENT
So Ordered
Electronically signed on 2014-05-15 15:27:14
2 of 2
E-FILED 2014 MAY 15 3:26 PM SAC - CLERK OF DISTRICT COURT