Curtis Santos

 
 Cause No. 80033214857 
 Curtis Santos 
 搂 
 IN THE DISTRICT COURT OF 
 搂 
 搂 
 vs. 
 搂 
 TARRANT COUNTY, TEXAS 
 DOLLAR GENERAL CORPORATION, 
 DOLGENCORP OF TEXAS, INC. 
 搂 
 352ND JUDICIAL DISTRICT 
 AFFIDAVIT 
 RECORDS PERTAINING TO: Curtis Santos 
 DATE OF SERVICE: 2019 May 20 to present 
 BEFORE 
 ME, 
 the 
 undersigned 
 authority 
 personally 
 appeared 
 Spencer Derrick 
 who, being by me duly sworn, deposed as follows:
 the record was made at or near the time of the act, event or condition recorded or reasonably soon thereafter. 
 1. Total amount of medical or health care expenses from your office billed for CLEMIS J. JAMISON 
 for 2019 May 20 to present $ 8,260.00 
 2. Total amount of medical or health care expenses that Curtis Santos has actually paid for 
 2019 May 20 to present which equals $ 
 0 
 The records attached copies of the microfiche on which 
 the image of the original documents have been transferred and nothing has been removed from the original file before 
 making these copies. 
 THE RECORDS ATTACHED HERETO ARE TRUE, CORRECT AND COMPLETE. FURTHER AFFIANT 
 SAITH NOT 
 Spencer arrick 
 Sherrie L. Galvan 
 SIGNATURE OF NOTARY PUBLIC IN AND FOR THE STATE OF TX 
 My Commission expires 
 2022 February 12 
 Order No. 98863.44
 FLAUG 
 Sherrie L Galvan 
 My Commission Expires 
 9/28/2028 
 Notary ID 
 140828189
