IN THE PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, PRESIDING JUDGE IN RE: ESTATE OF TAMIR RICE Decedent. Case No. 2014-EST-203019 Judge Laura J. Gallagher CREDITOR’S CLAIM FOR DECEDENT’S LAST DYING EXPENSE PURSUANT TO OHIO REVISED CODE §2117.25(A)(5) PLEASE TAKE NOTICE that the City of Cleveland (“Creditor”), located at 601 Lakeside Avenue, Room 122, Cleveland, Ohio 44114, has a claim against the Estate of Tamir Rice in the amount of Five Hundred Dollars ($500.00), see Exhibit A, which is past due and owing for emergency medical services rendered as the decedent’s last dying expense under Ohio Revised Code §2117.25(A)(5). This notice constitutes a presentation of a creditor’s claim pursuant to Ohio Revised Code §2117.06. Respectfully submitted, BARBARA A. LANGHENRY (0038838) DIRECTOR OF LAW /s/ Carl E. Meyer Carl E. Meyer (0089329) Assistant Director of Law 601 Lakeside Avenue, Room 106 Cleveland, Ohio 44114-1015 (216) 420-7610 (216) 664-4592 facsimile cmeyer@city.cleveland.oh.us Attorney for Creditor City of Cleveland CERTIFICATE OF SERVICE Pursuant to Civ. Pro. R. 5(B)(2)(f), I hereby certify that a true and accurate copy of this Creditor’s Claim for Decedent’s Last Dying Expense Pursuant to Ohio Revised Code §2117.25(A)(5) was served via electronic mail this February 10, 2016, upon the following counsel herein: Elizabeth A. Goodwin, Esq. egoodwin@gbs-llp.com Attorney for Estate Applicant Adam M. Fried, Esq. afried@reminger.com Attorney for Samaria Rice Diana M. Feitl, Esq. dfeitl@ralaw.com Attorney for Leonard Warner Timothy B. Pettorini, Esq. tpettorini@ralaw.com Attorney for Leonard Warner Douglass L. Winston, Esq. dwinston99@earthlink.net Attorney for Fiduciary BARBARA A. LANGHENRY (0038838) DIRECTOR OF LAW /s/ Carl E. Meyer Carl E. Meyer (0089329) Attorney for Creditor 2 IN THE PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, PRESIDING JUDGE Case No. 2014-EST-203019 IN RE: ESTATE OF TAMIR RICE Judge Laura J. Gallagher Decedent. AFFIDAVIT OF BECKY-LEE CARABALLO State of Ohio ) ) County of Cuyahoga ) ss: Becky-Lee Caraballo ("Affiant"), EMS Billing Manager of the City of Cleveland ("Creditor"), first being duly sworn according to law, deposes and states that Affiant has personal knowledge of the matters set forth herein except as specifically noted otherwise, and further states as follows: 1. Affiant is at least eighteen ( 18) years old and has personal knowledge of the matters set forth in this Affidavit; 2. That Affiant is the authorized representative of Creditor; 3. Affiant states that Creditor provided goods and/or services to the above-named Decedent pursuant to the terms of the parties' agreement; 4. Affiant states that the invoices, accounting statements and/or ledgers attached to the Creditor's Claim as Exhibit A are true and accurate; 5. Affiant states that Creditor keeps invoices, accounting, and/or ledger statements in the ordinary and normal course of business. 6. Affiant states that to date Decedent has failed to pay for the goods and/or services as agreed upon delineated in the invoices, accounting, and/or ledger statements. 7. Affiant states the amount owed by Decedent is $500.00. Furt er affiant sayeth not. I Becky-Lee Caraballo Sworn to before meand subscribed in my presence by the above-named Becky-Lee Caraballo this February 10, 2016. N~~ CARL E. MEYER, JR. Attorney At law Notary Public • State Of Ohio My commission has no expiration date Sec. 147.03 R.C. 3 Cleveland EMS I I I •• I • • 601 LAKESIDE AVE ROOM 127 CLEVELAND, OHIO 44114-1015 (216) 664-2598 CITY OF CLEVELAND Frank G. Jackson, Mayor Patient name: DEFENDANT'S~ EXHIBIT __---~~..A---1._____ Patient SSN: Run number: Date of call: Time of call: TAMIR RICE Ambulance Transportation Invoice Invoice Date: 02/10/2016 XXX-XX-0000 14-95624 11/22/2014 15:40 From: 1910 WEST BLVD CLEVELAND, OH 44102 To: METROHEAL TH MEDICAL CENTER TAMIR RICE 2006 W 1OOTH ST CLEVELAND, OH 44102 Primary payor: Molina Healthcare of Ohio, Inc Secondary payor: Bill Patient Description Check# Quantity Unit price 1.0 5.0 1.0 1.0 1.0 1.0 Ambulance Advance Life Support Mileage Contractual Allow-Contract Contractual Allow-Contract Payment-Check Revenue Adjustment Payment date Amount 450.00 10.00 450.00 50.00 (284.45) (42.65) (172.90) 500.00 1/21/2015 1/21/2015 2/12/2015 2/10/2016 $500.00 DETACH ALONG LINE AND RETURN STUB WITH YOUR PAYMENT. THANK YOU. Patient name: TAMIR RICE Run number: 14-95624 Remit to: Cleveland EMS 601 LAKESIDE AVE ROOM 127 CLEVELAND, OHIO 44114-1015 (216) 664-2598 Medicare#: I$ Amount enclosed:.__ _ _ _ _ ___, Due on: 03/11/2016 Medicaid#: Guarantor Name & Address: Insurance Name & Address: Insurance Policy#: Workers Comp. Claim#/Employe Insurance Group#: Date oflnjury: I AUTHORIZE THE CITY OF CLEVELAND EMS TO FILE A CLAIM WlTH MY INSURANCE COMPANY. MEDlCAL OR INFORMATION MAY BE RELEASED TO THE CARRIER UPON REQUEST. THIS BOX MUST BE SIGNED. SIGNATURE: DATE: