HomeMy WebLinkAbout941357
When Recorded
Return to:
RECEIVED 8/18/2008 at 11 :f7 ^ U
RECEIVING # 941357
BOOK: 702 PAGE: 524
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
e'Oú524
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: Ann Hansen
ADDRESS: 1110 Beech Avenue
Kemmerer, WY 83101
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Lot Seven (7) of Block Fifty-four (54) of Second Addition to the Town of
Kemmerer, Lincoln County, Wyoming as described on the official plat thereof
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 South Lincoln Hospital
and South Lincoln Nursing Center in Kemmerer, Wyoming and various other
providers on file with the Department of Health.
DATE OF SERVICE: 1/1/2098 to· present
AMOUNT DUE FOR CARE: $17,023.33
TOTAL AMOUNT DUEAND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEAL TH,FOR ALL CARE: $17,023.33.
THIS SECTION INTENTIONALLY LEFT BLANK
(-OùS25
IN WITNESS WHEREOF, I do hereunder set my hand thisa~ay of July 2008.
I EqualityCare
STATE OF WYOMING )
) ss.
COUNTY OF LARAMIE )
The foregoing Verified Lien Statement for Recipient Name was subscribed and
sworn to before me by Sheila Mcinerney this j~ day of July 2008.
WITNESS my hand and official seal.
My commission expires: ~ ; .201 (
~?
....;;;":~;:;......
':::.-~~-
~~/ ~-
Notar{Þublic
LESLIE MIlliKEN - NOTARY PUBLIC
COUNTY OF STATE OF
LARAMIE :1 WYOMING
MY COMMISSION EXPIRES AUG. 10,2011