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E S Legal Services, LLC
Post Office Box 3029
Cheyenne, WY 82003
NAME: Marion Allred
ADDRESS: 3555 Highway 241
Afton, WY 83110
RECEIVED 10/29/2009 at 9:59 AM
RECEIVING 950258
BOOK: 734 PAGE: 729
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 Healthcare
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:
LEGAL DESCRIPTION OF REAL PROPERTY:
State of Wyoming, County of Lincoln:
Beginning at a point which is 12 rods North from the Southeast Corner of the
Northeast Quarter of the Southeast Quarter (NE1 /4SE1/4) of Section 12 in
Township 31 North, Range 119 West of the Sixth Principal Meridian, and
running thence West 41.74 rods;
thence North 11.5 rods;
thence East 41.74 rods;
thence South 11.5 rods to the place of beginning.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were Star Valley Care Center
and Star Valley Hospital in Afton, Wyoming and various other providers on
file with the Department of Health.
00729
DATE OF SERVICE: July 1, 2007 to present
AMOUNT DUE FOR CARE: $100,651.45
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $100,651.45.
THIS SECTION INTENTIONALLY LEFT BLANK
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THIS SECTION INTENTIONALLY LEFT BLANK
2009.
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IN WITNESS WHEREOF, I do hereunder set my hand thisc day of October,
STATE OF WYOMING
ss.
COUNTY OF LARAMIE
This instrument was acknowledged before me on day of October, 2009 by
Sheila McInerney as Recovery Manger of the Wyoming Department of Health, Office of
Healthcare Financing.
nd and official seal.
State of Wyoming,
De artment of Heal
By: Sheila McInerney
Its: Recovery Manager
Notary Public
My Commission expires:
2
23 I l
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