Preview
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
State of Minnesota Conciliation Court
County Judicial District: FIFTH
LYON Court File Number:
Case Type: Conciliation
STATEMENT OF CLAIM AND SUMMONS
Plaintiff #1 Plaintiff #2
Name: AAA COLLECTIONS MIDWEST, INC. P Name:
Address: 3500 S. IST AVE, SUITE 100 L Address:
E
PO BOX 828 A
City/State/Zip: Sioux Fails, SD 57101-0828 s City/State/Zip:
E
vs VS
Defendant #1 p Defendant #2
Name: TROY JOSEPH WENZEL R Name:
Address: 231 2ND ST E Address:
I:
T
City/State/Zip: BALATON, MN 56115 City/State/Zip:
STATE OF SOUTH DAKOTA )
) ss
COUNTY OF MINNEHAHA )
PLAINTIFF’S STATEMENT OF CLAM
l. The Defendant(s) owe(s) AAA Collections Midwest, Inc. $448.60, plus filing fees and
costs of $75.00, and electronic filing fee of $5.00, for a total of $528.60 for service(s)
rendered as follows:
Service was provided by SANFORD HOME MED EQUIP to TROY JOSEPH WENZEL
on 8/21/2017, 9/21/2017, 10/21/2017, 11/21/2017
Principal $400.00 Interest $48.60
I believe the person(s) I am suing is/are at least 18 years old and not in the military
service.
Defendant #1 date of birth: 7/20/1971 Defendant #2 date of birth:
I understand that if I do not come to court on my hearing date, my case maybe dismissed
and I may have to pay money to the Defendant(s) on any counterclaim that has been
filed.
I declare under penalty of perjury that everything I have stated in this document is true and
correct. Minn. Stat. § 358.116.
{02002280.1}CCT102 State ENG Rev 7/15 www.mncourtsgov/forms
Page 1 of 2
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
THIS IS AN ATTEMPT T0 COLLECT A DEBT BY A DEBT COLLECTOR. ANY
INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
Date
{1* 1:} 41) W
Signatt’fi‘e
V
Printed Name: Rvan Dibbert
Title, if ahy: Legal Assistant
Address: PO Box 881
City/State/Zip: Sioux Falls, SD 57101-0881
Telephone: (605) 339-1333
SUMMONS: IMPORTANT NOTICE T0 THE PARTIES
You are hereby summoned to appear at the hearing of the above entitled case. See the attached
Notice of Hearing for time and location. If not attached, call Conciliation Court.
Failure of defendant to appear at the hearing may result in a default judgment being
entered for the plaintiff. Failure of the plaintiff to appear may result in dismissal of the
action or a default judgment being entered in favor of the defendant on any counterclaim
that has been filed.
The Defendant may bring a counterclaim against the Plaintiff. See “Information About
Conciliation Court” (court form CCTlOl) on the court forms webpage at
www.mncourts.gov/forms.
NOTICE OF SETTLEMENT
The above-entitled case having been settled, the same may be and hereby is dismissed with
my consent.
Date:
Plaintiff’ s Signature
{02002280.1}CCT102 State ENG Rev 7/15 www.mncourts.gov/forms
Page 2 of 2
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
M; ... WENZEL. free“; firoceeeefi
April 1%, 2820
AAA Account # 5127EQ
ASSIGNMENT
For valuable consideration, the undersigned does hereby
'aasign, and transfer unto AAA COLLECTIONS, INC., Aasignee
that certain claim of;
SANFORD HOME MED EQUIP, Creditor #35266
Against; TROY WENZEL, Consumer
amounting to $400.00 plus any applicable interest and fees
and does hexeby state that said claim is just and owing, true
and correct; and does hereby authorize the aasignee to bring
suit or action thereon in its own name and do any and all
things necessary to enforce collection of said claim as agent
for assignor.
:' W fl,
Date: “1/ "...-£313 £13
@030 0:2 B406 8/6
Signature
Printed
Y1?) trim...
Name «
V53}
Title““
:1 r v~
[ID ; Mug)” _
Principal Creditor Fee
{01.) B141025~1624738 Lioted Date: 04/06/2018 $100.00 $0.00
Memo: DME SSPPLY INVEN Date of Service: 08/21/2017
(02) Blé1025~1633325 Listed Date: 04/06/20l8 $100.00 $0.00
Memo: DME SUPPLY INVEN Date of Service; 09/21/2017
(03} 8141025—1663527 Listed Date: 04/06/2018 $100.00 $0.00
Memo: DME SQPPLY INVEN beta of Service: 10/21/2017
83%;025ml691340 Eifit 04X0$Z2018 $100.00 30 $0
{04)
Memo: Dog $UPPL¥ EKVEK Date of 3 11/21/2017
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
Sanfom Home Medical Equipment
PO BOX 84-906
SIOUX FALLS, SD 571184906 Xramfim
(505) 328 4438
Misc Customar
Prlnt Date 4/ 17/ 2020 Troy Joseph Wenzel
Firfi Print {2/15/2018 231 Znd St. E
Invoice 1624738 Bafiaton, MN 56115
Order 487876
Account No.
'
'Qb; .
Dafé sfiéfifimmhj gfihamnsjfiébl‘ts .iiayménts/firmfilfis';
3. 08/21/2017 796 $100.00
STEERABLE KNEE WALKER W/BASKET
let
Bllls every on theuntll returned.
03/21/2018 Write~0ff Collections $100.00
Total $100.00 $100.95
Balance $0.00
Payment Cash PAY THIS AMOUNT : $0.00
Comments
Name
CC #
Explres
Pace 1
87"} NW" 141025
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
5ami’onj ‘n’on’xe Medical Equlpn'leni:
9‘0 BOX 04906 .
gzzeux F Lfifi, 50 571184906 E fivgmgg
{6035}328 4438
Misc instomer
Print Date 4/17/2020 Troy Joseph Wenzel
First Print 5/ 15/2018 231 2nd St. E
Invoice 1633325 Balaton, MN 56115
Order 487876
Account No.
Qty >
>
»
mate .
_ bé‘scfifipfiéfi _:ciiarggsitigljig paymefiwcmm-
1 09/21/2017 795 $1oo‘oo
STEERABLE KNEE WALKER WIBASKET
Bills evexy on the 215: until returned,
0312112018 Write-Off Collections $100.00
Total $100.00 $100.00
Balance $0.00
Payment Check WCharge PAY THIS AMOUNT : $0.00
Cashmmmm
Comments
Name
““
CC # ..
.....
. .......
Expires
Page 1
BT~INV4~1=41025
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
Sanford Home Maximal Equipment
PO 80X 84906 “
SIOUX mm, SD 57118-4906 Eggyfigmggg
{6055}38 44-38
Misc Gusmmer
Prim; Bate 4/21.},‘2020 “Fwy Joseph Wanze}
Firfit' Print 5;"15i2018 231 “mi 53.. E.
invoice 1663527 Baiatun, MN 56115
Order 487876
Acmuul’ No.
Qty Eate Descripfian mama/whim;
'.
gamma-2mm
1 10/21/2017 796 $100.00
STEERABLE KNEE WALKER W/BASKET
let
Blils every on theunfil returned.
0312.1!201'8 Write-Off Collections $100.00
..
$100.00 $100.60
:IotaS
Balance $0.00
”Wm“ Cash ...... Check .................. Charge PAY THIS AMOUNT : $0.00
Comments
Name
CC I}
Expires;
BT~INV4~141025 Page 1
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
Sanford Home Medical Equipment
PO BOX 84906
Sioux FALLS, 80 571184906 Inmim
(605) 328 4438
Misc nsmmer
Print Date 4/ 17/2020 Troy Joseph Wenzel
First Print 5/16/2018 231 2nd St. E
Invoice 1691344 Balaton, MN 56115
Order #87876
Account No.
" '
' ’
929 ; Date
=
mergacm wages/newts ravmw‘riwia
1 11/21/2017 796 $100.00
STEERABLE KNEE WALKER W/BASKEI'
Zist untII returned.
Bills every on the
03/21/2018 Write~0fl Collections $100.00
Total $100.00 $100.00
Balance $0.00
Fame“ Gamma“..- Che“ WOW” a ............... PM THIS AMOUNT : $9.00
Comments
Name
CC #
”w
Explres
Page 1
{5T~INV4-141025
42-CO-20-319
Filed in District Court
State of Minnesota
12/17/2020 12:14 PM
./'
BfiLIVfiRV fiflfifi?
gamma: Harrie Maximal Elam 53:11am 38‘? Ml; “3:78;:
‘
'
1210 w 23m St suite anagram f‘alis, ssh 5271044549. phone: (50%;) 3284.445
Customermggearw WCHEE‘ ; TYKN 5 130B 07/2011971 Height Weight Saar M
Bill to 231 2nd St. 5 Deliver to 231 2nd St. E
Balaton, MN 56.115 Balaton, MN 56115
(50?) 539-9555 (507) 530-9555
lnsu rance MEDICA
Comments or Special Instructions l-(IPAA Signature on file Yes
In store pick up.
CN:
'
_‘8‘T7
Rezurn y July fist, 201?
l '
Tim-
[D'eil‘v'rary 'Datel
(:91? Branch
14/21/2017 Mary VanD'emark
[
am Ext. Amt. Tax C0435“;
Qty- |U0M |
"Wine i mm l l 1
Waruhouse VOM V _
1 EA Rental 796/SI‘EERABLEKNEE. WALKlEllW/BASKET $100.00 $0.90 $0.00
1 .
g
2m until
Bills every on the returned.
I.
TOTAL $100.00 $0.00 $0.00
f
.
v.
Ihave received: :1”, of Privacy Practices
Tfiptl'ce
tum/E Booklet (Rights. Responsibilities, Medicare Supplier Standards}
zjhm’é been instructed on haw and to use 8: do a return demonstration on the above equipmenllsupplies
“’Equipmem is in working order warranty Information(Owrxers Manual) reviewed
No RETURNS after 30 days. Receipt raqu‘ired.items that are personally worn, filled or used cannot be returned
servlces provided to me by Sanford
irequest that payment of benefits be made on my behalf to Sanford HME for any profiucis or
referredtoas SHME. authorize any holderofinsurance or medical informationabout me in release to SHME. my
HME. hereby l
whether the cost 0: products or
physician, caregiver. OMS or to any third party payer any Information needed to determine
l authorize release of information to any health related
services provided by SHME will be covered by any third party payor.
{or offinancialand while
quality monitoring. maintainingmy priVacy. l authorize SHME to bill for ongoing monthly
agency purpose
tals at the price listed equipment is returned. i agree that payment for above charges is my responsibility and that
,jli
Si 3% has not made guarant' o i agree that i am respcnsibte for returntof re: la! uquipmem
a'ymeni by any third party payer.
abovw k "i:..........
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f 1‘ \ [um-‘1. ..._._-_... .....
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Signature Relationship m Beneficiary (if Applicable) mm fc'a‘fi initials:
.
.ilfi‘ffifi
(ofiizfiintifiuzsruiimmlfirgsenmxiw}
t
, ”(a
=Lll\l~\\\
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fig“, i
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Thank Yau far Your amine“ ll!
mmmmm Custumm in 1.41325
Preview
42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM State of Minnesota Conciliation Court County Judicial District: FIFTH LYON Court File Number: Case Type: Conciliation STATEMENT OF CLAIM AND SUMMONS Plaintiff #1 Plaintiff #2 Name: AAA COLLECTIONS MIDWEST, INC. P Name: Address: 3500 S. IST AVE, SUITE 100 L Address: E PO BOX 828 A City/State/Zip: Sioux Fails, SD 57101-0828 s City/State/Zip: E vs VS Defendant #1 p Defendant #2 Name: TROY JOSEPH WENZEL R Name: Address: 231 2ND ST E Address: I: T City/State/Zip: BALATON, MN 56115 City/State/Zip: STATE OF SOUTH DAKOTA ) ) ss COUNTY OF MINNEHAHA ) PLAINTIFF’S STATEMENT OF CLAM l. The Defendant(s) owe(s) AAA Collections Midwest, Inc. $448.60, plus filing fees and costs of $75.00, and electronic filing fee of $5.00, for a total of $528.60 for service(s) rendered as follows: Service was provided by SANFORD HOME MED EQUIP to TROY JOSEPH WENZEL on 8/21/2017, 9/21/2017, 10/21/2017, 11/21/2017 Principal $400.00 Interest $48.60 I believe the person(s) I am suing is/are at least 18 years old and not in the military service. Defendant #1 date of birth: 7/20/1971 Defendant #2 date of birth: I understand that if I do not come to court on my hearing date, my case maybe dismissed and I may have to pay money to the Defendant(s) on any counterclaim that has been filed. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. {02002280.1}CCT102 State ENG Rev 7/15 www.mncourtsgov/forms Page 1 of 2 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM THIS IS AN ATTEMPT T0 COLLECT A DEBT BY A DEBT COLLECTOR. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. Date {1* 1:} 41) W Signatt’fi‘e V Printed Name: Rvan Dibbert Title, if ahy: Legal Assistant Address: PO Box 881 City/State/Zip: Sioux Falls, SD 57101-0881 Telephone: (605) 339-1333 SUMMONS: IMPORTANT NOTICE T0 THE PARTIES You are hereby summoned to appear at the hearing of the above entitled case. See the attached Notice of Hearing for time and location. If not attached, call Conciliation Court. Failure of defendant to appear at the hearing may result in a default judgment being entered for the plaintiff. Failure of the plaintiff to appear may result in dismissal of the action or a default judgment being entered in favor of the defendant on any counterclaim that has been filed. The Defendant may bring a counterclaim against the Plaintiff. See “Information About Conciliation Court” (court form CCTlOl) on the court forms webpage at www.mncourts.gov/forms. NOTICE OF SETTLEMENT The above-entitled case having been settled, the same may be and hereby is dismissed with my consent. Date: Plaintiff’ s Signature {02002280.1}CCT102 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 2 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM M; ... WENZEL. free“; firoceeeefi April 1%, 2820 AAA Account # 5127EQ ASSIGNMENT For valuable consideration, the undersigned does hereby 'aasign, and transfer unto AAA COLLECTIONS, INC., Aasignee that certain claim of; SANFORD HOME MED EQUIP, Creditor #35266 Against; TROY WENZEL, Consumer amounting to $400.00 plus any applicable interest and fees and does hexeby state that said claim is just and owing, true and correct; and does hereby authorize the aasignee to bring suit or action thereon in its own name and do any and all things necessary to enforce collection of said claim as agent for assignor. :' W fl, Date: “1/ "...-£313 £13 @030 0:2 B406 8/6 Signature Printed Y1?) trim... Name « V53} Title““ :1 r v~ [ID ; Mug)” _ Principal Creditor Fee {01.) B141025~1624738 Lioted Date: 04/06/2018 $100.00 $0.00 Memo: DME SSPPLY INVEN Date of Service: 08/21/2017 (02) Blé1025~1633325 Listed Date: 04/06/20l8 $100.00 $0.00 Memo: DME SUPPLY INVEN Date of Service; 09/21/2017 (03} 8141025—1663527 Listed Date: 04/06/2018 $100.00 $0.00 Memo: DME SQPPLY INVEN beta of Service: 10/21/2017 83%;025ml691340 Eifit 04X0$Z2018 $100.00 30 $0 {04) Memo: Dog $UPPL¥ EKVEK Date of 3 11/21/2017 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM Sanfom Home Medical Equipment PO BOX 84-906 SIOUX FALLS, SD 571184906 Xramfim (505) 328 4438 Misc Customar Prlnt Date 4/ 17/ 2020 Troy Joseph Wenzel Firfi Print {2/15/2018 231 Znd St. E Invoice 1624738 Bafiaton, MN 56115 Order 487876 Account No. ' 'Qb; . Dafé sfiéfifimmhj gfihamnsjfiébl‘ts .iiayménts/firmfilfis'; 3. 08/21/2017 796 $100.00 STEERABLE KNEE WALKER W/BASKET let Bllls every on theuntll returned. 03/21/2018 Write~0ff Collections $100.00 Total $100.00 $100.95 Balance $0.00 Payment Cash PAY THIS AMOUNT : $0.00 Comments Name CC # Explres Pace 1 87"} NW" 141025 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM 5ami’onj ‘n’on’xe Medical Equlpn'leni: 9‘0 BOX 04906 . gzzeux F Lfifi, 50 571184906 E fivgmgg {6035}328 4438 Misc instomer Print Date 4/17/2020 Troy Joseph Wenzel First Print 5/ 15/2018 231 2nd St. E Invoice 1633325 Balaton, MN 56115 Order 487876 Account No. Qty > > » mate . _ bé‘scfifipfiéfi _:ciiarggsitigljig paymefiwcmm- 1 09/21/2017 795 $1oo‘oo STEERABLE KNEE WALKER WIBASKET Bills evexy on the 215: until returned, 0312112018 Write-Off Collections $100.00 Total $100.00 $100.00 Balance $0.00 Payment Check WCharge PAY THIS AMOUNT : $0.00 Cashmmmm Comments Name ““ CC # .. ..... . ....... Expires Page 1 BT~INV4~1=41025 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM Sanford Home Maximal Equipment PO 80X 84906 “ SIOUX mm, SD 57118-4906 Eggyfigmggg {6055}38 44-38 Misc Gusmmer Prim; Bate 4/21.},‘2020 “Fwy Joseph Wanze} Firfit' Print 5;"15i2018 231 “mi 53.. E. invoice 1663527 Baiatun, MN 56115 Order 487876 Acmuul’ No. Qty Eate Descripfian mama/whim; '. gamma-2mm 1 10/21/2017 796 $100.00 STEERABLE KNEE WALKER W/BASKET let Blils every on theunfil returned. 0312.1!201'8 Write-Off Collections $100.00 .. $100.00 $100.60 :IotaS Balance $0.00 ”Wm“ Cash ...... Check .................. Charge PAY THIS AMOUNT : $0.00 Comments Name CC I} Expires; BT~INV4~141025 Page 1 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM Sanford Home Medical Equipment PO BOX 84906 Sioux FALLS, 80 571184906 Inmim (605) 328 4438 Misc nsmmer Print Date 4/ 17/2020 Troy Joseph Wenzel First Print 5/16/2018 231 2nd St. E Invoice 1691344 Balaton, MN 56115 Order #87876 Account No. " ' ' ’ 929 ; Date = mergacm wages/newts ravmw‘riwia 1 11/21/2017 796 $100.00 STEERABLE KNEE WALKER W/BASKEI' Zist untII returned. Bills every on the 03/21/2018 Write~0fl Collections $100.00 Total $100.00 $100.00 Balance $0.00 Fame“ Gamma“..- Che“ WOW” a ............... PM THIS AMOUNT : $9.00 Comments Name CC # ”w Explres Page 1 {5T~INV4-141025 42-CO-20-319 Filed in District Court State of Minnesota 12/17/2020 12:14 PM ./' BfiLIVfiRV fiflfifi? gamma: Harrie Maximal Elam 53:11am 38‘? Ml; “3:78;: ‘ ' 1210 w 23m St suite anagram f‘alis, ssh 5271044549. phone: (50%;) 3284.445 Customermggearw WCHEE‘ ; TYKN 5 130B 07/2011971 Height Weight Saar M Bill to 231 2nd St. 5 Deliver to 231 2nd St. E Balaton, MN 56.115 Balaton, MN 56115 (50?) 539-9555 (507) 530-9555 lnsu rance MEDICA Comments or Special Instructions l-(IPAA Signature on file Yes In store pick up. CN: ' _‘8‘T7 Rezurn y July fist, 201? l ' Tim- [D'eil‘v'rary 'Datel (:91? Branch 14/21/2017 Mary VanD'emark [ am Ext. Amt. Tax C0435“; Qty- |U0M | "Wine i mm l l 1 Waruhouse VOM V _ 1 EA Rental 796/SI‘EERABLEKNEE. WALKlEllW/BASKET $100.00 $0.90 $0.00 1 . g 2m until Bills every on the returned. I. TOTAL $100.00 $0.00 $0.00 f . v. Ihave received: :1”, of Privacy Practices Tfiptl'ce tum/E Booklet (Rights. Responsibilities, Medicare Supplier Standards} zjhm’é been instructed on haw and to use 8: do a return demonstration on the above equipmenllsupplies “’Equipmem is in working order warranty Information(Owrxers Manual) reviewed No RETURNS after 30 days. Receipt raqu‘ired.items that are personally worn, filled or used cannot be returned servlces provided to me by Sanford irequest that payment of benefits be made on my behalf to Sanford HME for any profiucis or referredtoas SHME. authorize any holderofinsurance or medical informationabout me in release to SHME. my HME. hereby l whether the cost 0: products or physician, caregiver. OMS or to any third party payer any Information needed to determine l authorize release of information to any health related services provided by SHME will be covered by any third party payor. {or offinancialand while quality monitoring. maintainingmy priVacy. l authorize SHME to bill for ongoing monthly agency purpose tals at the price listed equipment is returned. i agree that payment for above charges is my responsibility and that ,jli Si 3% has not made guarant' o i agree that i am respcnsibte for returntof re: la! uquipmem a'ymeni by any third party payer. abovw k "i:.......... \ - ,1 f 1‘ \ [um-‘1. ..._._-_... ..... ‘ . Signature Relationship m Beneficiary (if Applicable) mm fc'a‘fi initials: . .ilfi‘ffifi (ofiizfiintifiuzsruiimmlfirgsenmxiw} t , ”(a =Lll\l~\\\ ”W ' fig“, i ', ''' Thank Yau far Your amine“ ll! mmmmm Custumm in 1.41325