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PO Box 3029
Cheyenne, WY 82003
RECEIVED 6/3/2005 at 1-1:38 AM ' --
RECEIVING # 908915
BOOK: 587 PAGE: 136
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT: State of Wyoming, Department of Health, Office of Medicaid
ADDRESS: 6101 Yellowstone Road, Suite 210
Cheyenne, Wyoming 82002
NAME AND ADDRESS OF PERSON TO WHOM MEDICAL CARE WAS FURNISHED
AND AGAINST WHOSE PROPERTY LIEN IS FILED:
NAME:
ADDRESS:
Elinor Brown
169 W. 1st
Fairview, WY 83119
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Commencing at a point which is 40 rods West and 20 rods South from the Northeast
corner of the NE1/4NW1/4 of Section 10, T31N R119W of the 6th P.M., Lincoln County,
Wyoming and running thence South 14 rods; thence West 15 rods; thence North 14 rods;
thence East 15 rods to the place of beginning, being a part of what is Lot 5 in Block 2 of the
Fairview, Wyoming Townsite. Together with all improvements situate thereon and all
easements and appurtenances belonging thereto.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendOrs providing medical care were Medical Mart, Family
Pharmacy, and Star Valley Hospital in Alton, Wyoming, and various other
providers on file with the Department of Health.
DATE OF SERVICE: 11/1/1990 to present
AMOUNT DUE FOR CARE: $48,063.77
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $48,063.77
00.I_37
_ //~
IN WITNESS WHEREOF, I do hereunder set my hand this/3~day of May, 2005.
State of Wyoming,
¢--"-~-~ent of Health
/ \ ~--/<_/___%..,,
F:-_ ./ ,,,, '4
' By: Debbie Paiz '-"
Its: Recovery Manager '""----._~
STATE OF WYOMING )
) SS.
COUNTY OF LARAMIE )
The foregoing Verified Lien Statement for Elinor Brown was subscribed and sworn
to before me by Debbie Paiz this. f~')'t~ay of May, 2005.
My Commission expires:
WITNESS my hand and official seal.
C...-'" Notary Public