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E S Legal Services, LLC
PO Box 3029
Cheyenne, WY 82003
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT: State of Wyoming
Department of Health
Office of Healthcare Financing/EqualityCare
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: Dorthea Jiacoletti
ADDRESS: 1039 Beech Avenue
Kemmerer, Wyoming 83101
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Lot 11 of Block 45 of the Second Addition to the Town of Kemmerer, Lincoln County,
Wyoming as described on the official plat thereof.
ALSO, the Northerly 4 feet, 2 inches of Lot 10 of Block 45 of the Second Addition to the Town
of Kemmerer, Lincoln County, Wyoming more particularly described by metes and bounds as
follows:
BEGINNING at the Northeasterly corner of said Lot 10 and running thence Southerly along the
Easterly boundary of said Lot, a distance of 4 feet, 2 inches; thence Westerly, parallel with the
Northerly and Southerly boundaries of said Lot 10, a distance of 125 feet to the Westerly
boundary of said Lot; thence Northerly 4 feet, 2 inches, to the Northwesterly corner of said Lot;
thence Easterly, 125 feet to the Northeasterly corner of said Lot, the PLACE OF BEGINNING
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 Nursing Center
Located in Kemmerer, Wyoming, and various other providers on file with the
Department of Health.
DATE OF SERVICE: 04/01/2006 to present
AMOUNT DUE FOR CARE: 212,830.54
520
RECEIVED 6/7/2010 at 10:31 AM
RECEIVING 953846
BOOK: 748 PAGE: 520
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 212,830.54
IN WITNESS WHEREOF, I do hereunder set my hand this day of June 2010.
STATE OF WYOMING
COUNTY OF LARAMIE
WITNESS my hand and official seal.
LESLIE MILLIKEN NOTARY PUBLIC
COUNTY OF t STATE OF
LARAMIE WYOMING
MY COMMISSION EXPIRES AUG 10, 2011
ss.
State of Wyoming,
Department of Health
Of i e ca•Enancing /EqualityCare
By: Sheila McInerney
Its: TPL /Recovery Coordinator
This instrument was acknowledged before me on day of June, 2010 by Sheila
McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health, Office of
Healthcare Financing.
Notary Public
My commission expires:
C,O, Y 5