HomeMy WebLinkAbout937294
lNhen Recorded
Return to:
RECEIVED 3/3/2008 at 12:46 PM
RECEIVING # 937294
BOOK: 688 PAGE: 400
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
ùOi)400
E & S Legal Services, LLC
Post Office Box 3029
Cheyenne,VVY 82003
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE-
NAME OF CLAIMANT: State of Wyoming, Department of Health, Office of Health Care
Financing
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: Nellie Martin
ADDRESS: 531 Adams Street
Afton, WY 83110
LEGAL DESCRIPTION OF REAL PROPERTY:
~
Part of Lot 2 of Block 28 of the Afton Townsite, Lincoln County, Wyoming
being described as follows:
Con1mencing at a point which is 9 1/3 rods and 12 feet;
thenþe South 4 2/3 rods;
thence West 6 rods and 12 rods;
thence North 4 2/3 rods to the point of beginning.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were Star Valley Care Center
and Valley Pharmacy in Afton, Wyoming and various other providers on file
with the Department of Health.
DATE OF SERVICE: 12/1/1998 to present
AMOUNT DUE FOR CARE: $179,895.36
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $179,895.36.
THIS SECTION INTENTIONALLY LEFT BLANK
1
õOð401
IN WITNESS WHEREOF, I do hereunder set my hand this r~ay of February,
2008.
State of Wyoming,
Department of Health~.~---"·_"~·'''''''''""
;,~,. "\
,. ,
, .
/
STATE OF WYOMING )
) ss.
COUNTY OF LARAMIE )
The foregoing instrument was acknowledged before me by Sheila Mcinerney this li
day of February, 2008.
WITNESS my hand and official seal.
~!:/~<V:~^~,. .
~~ cVNni.:k:·~::b«~·;~"'N· ··ÑoTÃFri Pllli'~~?~'.
4\." , . .~\
~ r.Oll~ITV OF '" STATE OF j.,
;': 1.r,lli;."'f ~:' ,WYOMING«
<' '. '.. '~:þ' ~~
MV COMI.IISSìù¡·¡ ;iA¡:' R':S ;'PR. 1:J. 20¡)~
~~:b> ¡(. ¿JcJ:~
N ry Pu lie
My Commission expires: 4 . t 3 . () CJ
2