On March 06, 2024 a
Statement of Claim Index #1
was filed
involving a dispute between
Range Credit Bureau, Inc,
and
Somora, Kailey,
for Conciliation
in the District Court of Carlton County.
Preview
09-CO-24-110
Filed in District Court
State of Minnesota
3/6/2024 9:32 PM
State of Minnesota Conciliation Court
County of: CARLTON Judicial District: SIXTH
Court File Number:
Case Type: Conciliation
PLAINTIFF'S STATEMENT 0F CLAIM
Plaintiff #1 Plaintiff #2
Name: RANGE CREDIT BUREAU INC Name:
Address: PO BOX 706 Address:
City,/State..»'Zip HIBBING MN 55746 City/Statef'Zip:
Defendant #1 Defendant #2
Name: Kailey Somora Name:
Address: 4 l22 Tw'in Lakes Dr Address:
City/StateJZip: CLOQUET MN 55720-9316 City.!'$tate..~'Zip
E Check box if there are more than two plaintiffs or more than two defendants. List the
information for the other parties on the Additional Litigants Form, CCT702.
Information about the Defendant
1. How many defendants are there? l
a. Defendant # 1
Name: KaileV' Somora
D fl Individual (Person)
Business
IfDefendant # 1 is an individual.'
'
i. I believe Defendant #1 is at least 18 years oid.
Date ofbirth: 11/26/1997 f DUnknown.
ii. About military service:
D Defendant #1 is in the military service
I Defendant #1 is not in the military service
D Unknown.
b. Defendant # 2
Name:
fl Individual (Person) DBusiness
IfDefendant # 2 is an individual.'
i. I believe Defendant #2 is at least 18 years old.
Plaintiff's Statement of Claim
CCT102 State ENG Rev 10/20 www.mncourts.govlfonns Page 1 of 3
09-CO-24-110
Filed in District Court
State of Minnesota
3/6/2024 9:32 PM
Date of birth: / Unknown.
ii. About military service:
S Defendant # 2 is in the military service
I Defendant # 2 is not in the military service
Unknown.
If there are more than 2 defendants, use the Additional Litigants Form (CCT702).
Information about the Claim
2. I am filing this claim against Defendant for: (check all that apply}
Money
_l The Defendant owes me $ 752.26 , plus filing fees and costs in the amount of
$ 80-00 ,somytotalclaimisfor $ 832-26
(amount Defendant owes plus filing fees and costs). I have a claim for this
amount because in
02/07/2023 (month and year), the following happened (briefly describe):
SEE ATTACHED
**IN REGARDS TO INTEREST SEE MN STATUTE 334.0]
**IN REGARDS TO NSF & CIVIL PENALTIES SEE MN STATUTE 604.113
"m REGARDS TO HUSBAND AND WIFE LIABILITY SEE MN STATUTE 519.05
PropertJI
D The Defendant has the following propexty that belongs to me (list property):
My property is valued at $ - The filing fees and costs for this case are
Plaintiff's Statement of Claim
CCT102 State ENG Rev 10/20 www.mnoourts.govlforms Page 2 of 3
09-CO-24-110
Filed in District Court
State of Minnesota
3/6/2024 9:32 PM
$ . I want the court to order this property returned to me or make the
Defendant pay me $ (property's value plus the filing fees and costs).
3. I understand that if I do not come to court on my hearing date, m)' case may be dismissed and
I may have to pay money to the Defendant on any counterclaim that has been filed.
Important! Each plaintiff must sign the Statement of Claim form and include the date signed,
the name of the state and count}! where signed, and provide the following information: title, if
any, telephone number, date of birth, and e-mail address.
I declare under penalty of perjury' that everything that I have stated in this document is true and
correct. Minn. Stat. § 358.116.
Signature (Plaintiff #1) Signature (Plaintiff #2)
OR D There is onl§' l plaintiff
DATEz02/24/2024 DATE;
ST. LOUIS
Counti' arid State Where Signed County and State where signed
S.H. CAUCCl
Name Name
PRESIDENT
if any
Title, Title, if any
218-263-8886
Telephone Telephone
Date of birtll Date of birth
legal@rcbcollections.com
Email Address Email Address
NOTE: If there are more than 2 plaintiffs, all of the other plaintiffs must sign the Statement of
Claim form and include the information listed above.
Plaintiff's Statement of Claim
CCT102 State ENG Rev 10/20 www.mncourts.govlforms Page 3 of 3
09-CO-24-110
Filed in District Court
State of Minnesota
3/6/2024 9:32 PM
STATEMENT OF CLAIMS ATTACHMENT
COUNTY: CARLTON COUNTY
DEBTOR: Kailey Roselynn Somora 112ND LOC:
DEBTOR #2:
ADDRESS: 4122 Twin Lakes Dr
CLOQUET MN 55720-9316
NOTICE WAS MAILED TO THE DEFENDANT ADVISING OF COLLECTION ACCOUNTS AND/OR
DISHONORED CHECKS, SERVICE CHARGES AND PENALTIES. DEMAND IS HEREBY
MADE AS FOLLOWS:
LIST OF ACCOUNTS
CLIENT PRINCIPAL NSF FEE CIVIL PNL INTEREST COURT TOTAL DUE
NORTHERN ORAL & M $669.50 $0.00 $0.00 $82.76 $80.00 $832.26
THIS IS AN ATTEMPT TO COLLECT A DEBT.
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
09-CO-24-110
Filed in District Court
State of Minnesota
3/6/2024 9:32 PM
RCB COLLECTIONS range credit bureau inc.
310 E HOWARD ST
PO BOX 706
HIBBING MN 55746
218m263-8886 800-4777046 iittiffl
RE: Kailey Roselynn Somora
PATIENT:
ashley bus office Account #: .......
NORTHERN ORAL & MAXILLOFACIALDLTH Balance: $669.50
3617 W ARROWHEAD RD Date Listed: 07/03/2023
DULUTH MN 55811-4046
-
Imo'nn.'
Date: 01/12/2024
We are in the process of taking legal action on the above account.
Please sign this assignment and return promptly. Kindly accept
no payments from the debtor. Call us at once if the debtor
should contact you. Thank you.
Do you know of employment for Kailey Roselynn Samara?
Um Lxm. NW
Please attach an itemized statement
ASSIGNMENT
Account #:
For valuable consideration we do hereby sell, assign, and transfer
unto RCB Collections range credit bureau,inc. that certain claim
of NORTHERN ORAL E MAXILLOFACIAL-DLTH against
Kailey Roselynn Sonora (and/or) (and/or)
Sonora, Railey amounting to $669.50
and we do hereby authorize RCB Collections range credit bureau, inc.
to bring action or suit thereon in their own name and to do
any and all things necessary to enforce collection of the said claim.
Acct: -fln
Dated this 2U day of j?.r\.uLa-r--\' LEI/4.
NORTHERN FA I -
TH
Name of Creditor
By
X;M ' gi}-vw\
A'"
RCB Collections range credit bureau, inc.
This collection agency is licensed by the uinnesota Department or Gomez-cc.
This is an attempt to collect a debt. any intonation obtained will be used for that purpose.
09-CO-24-110
Filed in District Court
State of Minnesota
Ledger Itemized View Report 3/6/2024 9:32 PM
Samara, Kelley
Date Office Prv Code 4Dscrlpu'm T# Comet Amount
12:13an1
12/29/2022 10
5-? 3?
lnsuranceDel'lied-
8;? «<19; m 53"?»
I».
D-elta denied
v
-,
'5'"? at My .102. $451625
evaI/rrequcy limit 102.00
ii
.4.
[law/2022." 35% -1. [ 9»
02/07/2023 1 Per Kelley Samara 43550 .11350
Wfffifik" WWfl
U ,
.Al-W*L' "ad/fix "
-m&w
>
I."
,,
Auk-yum
Vla>>P§vment '
'. h:
o) '2
1o
Insuanee
Denied Delta denied
surgery/not ellglble
0.00
'50 (915M 3"? 717)
Géq T0
f H'3? a "(OM
1767??
Cumtf 31-60 | 61-90 91-120] 121+
$0.00 mod $0.00 .'
$0M $56
Page 1 of 1 01-26-24
Document Filed Date
March 06, 2024
Case Filing Date
March 06, 2024
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Preview
09-CO-24-110 Filed in District Court State of Minnesota 3/6/2024 9:32 PM State of Minnesota Conciliation Court County of: CARLTON Judicial District: SIXTH Court File Number: Case Type: Conciliation PLAINTIFF'S STATEMENT 0F CLAIM Plaintiff #1 Plaintiff #2 Name: RANGE CREDIT BUREAU INC Name: Address: PO BOX 706 Address: City,/State..»'Zip HIBBING MN 55746 City/Statef'Zip: Defendant #1 Defendant #2 Name: Kailey Somora Name: Address: 4 l22 Tw'in Lakes Dr Address: City/StateJZip: CLOQUET MN 55720-9316 City.!'$tate..~'Zip E Check box if there are more than two plaintiffs or more than two defendants. List the information for the other parties on the Additional Litigants Form, CCT702. Information about the Defendant 1. How many defendants are there? l a. Defendant # 1 Name: KaileV' Somora D fl Individual (Person) Business IfDefendant # 1 is an individual.' ' i. I believe Defendant #1 is at least 18 years oid. Date ofbirth: 11/26/1997 f DUnknown. ii. About military service: D Defendant #1 is in the military service I Defendant #1 is not in the military service D Unknown. b. Defendant # 2 Name: fl Individual (Person) DBusiness IfDefendant # 2 is an individual.' i. I believe Defendant #2 is at least 18 years old. Plaintiff's Statement of Claim CCT102 State ENG Rev 10/20 www.mncourts.govlfonns Page 1 of 3 09-CO-24-110 Filed in District Court State of Minnesota 3/6/2024 9:32 PM Date of birth: / Unknown. ii. About military service: S Defendant # 2 is in the military service I Defendant # 2 is not in the military service Unknown. If there are more than 2 defendants, use the Additional Litigants Form (CCT702). Information about the Claim 2. I am filing this claim against Defendant for: (check all that apply} Money _l The Defendant owes me $ 752.26 , plus filing fees and costs in the amount of $ 80-00 ,somytotalclaimisfor $ 832-26 (amount Defendant owes plus filing fees and costs). I have a claim for this amount because in 02/07/2023 (month and year), the following happened (briefly describe): SEE ATTACHED **IN REGARDS TO INTEREST SEE MN STATUTE 334.0] **IN REGARDS TO NSF & CIVIL PENALTIES SEE MN STATUTE 604.113 "m REGARDS TO HUSBAND AND WIFE LIABILITY SEE MN STATUTE 519.05 PropertJI D The Defendant has the following propexty that belongs to me (list property): My property is valued at $ - The filing fees and costs for this case are Plaintiff's Statement of Claim CCT102 State ENG Rev 10/20 www.mnoourts.govlforms Page 2 of 3 09-CO-24-110 Filed in District Court State of Minnesota 3/6/2024 9:32 PM $ . I want the court to order this property returned to me or make the Defendant pay me $ (property's value plus the filing fees and costs). 3. I understand that if I do not come to court on my hearing date, m)' case may be dismissed and I may have to pay money to the Defendant on any counterclaim that has been filed. Important! Each plaintiff must sign the Statement of Claim form and include the date signed, the name of the state and count}! where signed, and provide the following information: title, if any, telephone number, date of birth, and e-mail address. I declare under penalty of perjury' that everything that I have stated in this document is true and correct. Minn. Stat. § 358.116. Signature (Plaintiff #1) Signature (Plaintiff #2) OR D There is onl§' l plaintiff DATEz02/24/2024 DATE; ST. LOUIS Counti' arid State Where Signed County and State where signed S.H. CAUCCl Name Name PRESIDENT if any Title, Title, if any 218-263-8886 Telephone Telephone Date of birtll Date of birth legal@rcbcollections.com Email Address Email Address NOTE: If there are more than 2 plaintiffs, all of the other plaintiffs must sign the Statement of Claim form and include the information listed above. Plaintiff's Statement of Claim CCT102 State ENG Rev 10/20 www.mncourts.govlforms Page 3 of 3 09-CO-24-110 Filed in District Court State of Minnesota 3/6/2024 9:32 PM STATEMENT OF CLAIMS ATTACHMENT COUNTY: CARLTON COUNTY DEBTOR: Kailey Roselynn Somora 112ND LOC: DEBTOR #2: ADDRESS: 4122 Twin Lakes Dr CLOQUET MN 55720-9316 NOTICE WAS MAILED TO THE DEFENDANT ADVISING OF COLLECTION ACCOUNTS AND/OR DISHONORED CHECKS, SERVICE CHARGES AND PENALTIES. DEMAND IS HEREBY MADE AS FOLLOWS: LIST OF ACCOUNTS CLIENT PRINCIPAL NSF FEE CIVIL PNL INTEREST COURT TOTAL DUE NORTHERN ORAL & M $669.50 $0.00 $0.00 $82.76 $80.00 $832.26 THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. 09-CO-24-110 Filed in District Court State of Minnesota 3/6/2024 9:32 PM RCB COLLECTIONS range credit bureau inc. 310 E HOWARD ST PO BOX 706 HIBBING MN 55746 218m263-8886 800-4777046 iittiffl RE: Kailey Roselynn Somora PATIENT: ashley bus office Account #: ....... NORTHERN ORAL & MAXILLOFACIALDLTH Balance: $669.50 3617 W ARROWHEAD RD Date Listed: 07/03/2023 DULUTH MN 55811-4046 - Imo'nn.' Date: 01/12/2024 We are in the process of taking legal action on the above account. Please sign this assignment and return promptly. Kindly accept no payments from the debtor. Call us at once if the debtor should contact you. Thank you. Do you know of employment for Kailey Roselynn Samara? Um Lxm. NW Please attach an itemized statement ASSIGNMENT Account #: For valuable consideration we do hereby sell, assign, and transfer unto RCB Collections range credit bureau,inc. that certain claim of NORTHERN ORAL E MAXILLOFACIAL-DLTH against Kailey Roselynn Sonora (and/or) (and/or) Sonora, Railey amounting to $669.50 and we do hereby authorize RCB Collections range credit bureau, inc. to bring action or suit thereon in their own name and to do any and all things necessary to enforce collection of the said claim. Acct: -fln Dated this 2U day of j?.r\.uLa-r--\' LEI/4. NORTHERN FA I - TH Name of Creditor By X;M ' gi}-vw\ A'" RCB Collections range credit bureau, inc. This collection agency is licensed by the uinnesota Department or Gomez-cc. This is an attempt to collect a debt. any intonation obtained will be used for that purpose. 09-CO-24-110 Filed in District Court State of Minnesota Ledger Itemized View Report 3/6/2024 9:32 PM Samara, Kelley Date Office Prv Code 4Dscrlpu'm T# Comet Amount 12:13an1 12/29/2022 10 5-? 3? lnsuranceDel'lied- 8;? «<19; m 53"?» I». D-elta denied v -, '5'"? at My .102. $451625 evaI/rrequcy limit 102.00 ii .4. [law/2022." 35% -1. [ 9» 02/07/2023 1 Per Kelley Samara 43550 .11350 Wfffifik" WWfl U , .Al-W*L' "ad/fix " -m&w > I." ,, Auk-yum Vla>>P§vment ' '. h: o) '2 1o Insuanee Denied Delta denied surgery/not ellglble 0.00 '50 (915M 3"? 717) Géq T0 f H'3? a "(OM 1767?? Cumtf 31-60 | 61-90 91-120] 121+ $0.00 mod $0.00 .' $0M $56 Page 1 of 1 01-26-24