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COUNTY OF LARAMIE
AFFIDAVIT FOR COLLECTION OF CLAIMS OF
CERTAIN CREDITORS OF DECEDENT
PURSUANT TO WYOMING STATUTE 2 -1 -204
069
I, Sheila McInerney, TPL /Recovery Coordinator, State of Wyoming, Department
of Health, Office of Healthcare Financing, being first duly sworn on oath depose and
state that I am making this affidavit pursuant to Wyoming Statutes 2 -1 -204 on behalf
of the State of Wyoming, Department of Health, Office of Healthcare Financing, as a
creditor of the decedent's estate, and that I make the following statements in connection
therewith:
1. Eleanor Lyons Wilson became deceased on March 13, 2006 and was a resident
of Lincoln County, State of Wyoming at the time of death; that the decedent died
intestate; the decedent left no surviving spouse; the sole and only party entitled
to the estate of the decedent is the Department of Health, Office of Healthcare
Financing, as hereinafter named.
2. The value of the estate, wherever located, does not exceed $150,000.00.
3. More than ninety days have elapsed since the death of the decedent.
4. No application for the appointment of a personal representative of said decedent
is pending or has been granted in any jurisdiction.
5. To the best of my knowledge no affidavit pursuant to Wyoming Statute 2 -1 -201,
in connection with the decedent, has been presented to any party identified in
that section.
6. This creditor's claim is presented on the following facts:
a. That Eleanor Wilson received medical assistance pursuant to Title XIX of
the Social Security Act, as amended, and the Wyoming Medical
Assistance and Services Act, as amended, in the amount of Three
Hundred Forty Nine Thousand Nine Hundred Thirty Six Dollars and
Seventy -five Cents ($349,936.75), such care being provided by Star
Valley Care Center, and Family Pharmacy in Afton, Wyoming and by other
providers on file with the Department of Health.
b. That Eleanor Wilson was a "recipient" as defined by applicable Medicaid
law.
c. That Eleanor Wilson was age Sixty Five (65) or older when she received
$349,936.75 of such reimbursable medical assistance for nursing facility
services, home and community -based services, related hospital and
prescription drug services, and any items under the Wyoming State Plan.
That Eleanor Wilson was an inpatient in a nursing facility, intermediate
care facility, or other medical institution when she received $349,936.75 of
such reimbursable medical assistance.
7. That by presentation of this affidavit,
Health, Office of Healthcare Financing:
a. Waives any immunity from suit
have;
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the State of Wyoming, Department of
or levy of execution it might otherwise
RECEIVED 9/1/2010 at 9:59 AM
RECEIVING 955279
BOOK: 753 PAGE: 69
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
000070
b. Agrees to indemnify and hold harmless from all 'claims whatsoever any
party delivering assets on the basis of such affidavit, to the extent of the
full value of the assets so delivered; and,
c. Agrees to be answerable and accountable to a personal representative of
the estate, if appointed, or to any other person or party having a superior
right.
8. The following named creditor is the sole and only party entitled to the estate of
the decedent, that there are no other distributees of the decedent having a right
to succeed to any of the property of the decedent under probate proceedings,
and that therefore the following named claiming creditor is entitled to payment or
decedent's property:
The proceeds of a life insurance policy with Sociedade Portuguesa
9. The original of this affidavit is being filed of record with the County Clerk of
Lincoln, Wyoming, in accordance with Wyoming Statutes 2- 1- 204(b) and 2 -1-
201(c), as amended.
Executed at Cheyenne, Wyoming, this
WITNESS my hand and official seal.
5 l day of August, 2010.
STATE OF WYOMING,
DEPARTMENT OF HEALTH,
OFFICE OF HEALTHCARE FINANCING:
Signed:
By: Sheila McInerney
TPL /Recovery Coordinator
Wyoming Office of Healthcare Financing
6101 Yellowstone Road, Suite 210
Cheyenne, WY 82002
(307) 777 -7531
Subscribed and sworn to before me by Sheila McInerney, TPL /Recovery
Coordinator, for the State of Wyoming, Department of Health, Office of Healthcare
V P-I)
Financing, this day of August, 2010.
Notary Public
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