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E S Legal Services, LLC
Post Office Box 3029
Cheyenne, WY 82003
NAME: Agnes Guyette
ADDRESS 267 S. Blake Street
LaBarge, Wyoming 83123
RECEIVED 9/3/2010 at 9:34 AM
RECEIVING 955311
BOOK: 753 PAGE: 144
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:
County of Lincoln, State of Wyoming
An undivided 1/3 interest in Lots numbered 11 and 12 of Block "B" of the Riverview
Addition to the Town of Tulsa, now LaBarge, Lincoln County, Wyoming as
described on the official plat filed on February 28, 1927 as Map No. 153 of the
records of the Lincoln County Clerk
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were Wind River Healthcare Rehab
Center in Riverton, Wyoming and various other providers on file with the
Department of Health.
DATE OF SERVICE: 10/01/2008 to present
AMOUNT DUE FOR CARE: $68,397.97
THIS SECTION INTENTIONALLY LEFT BLANK
1
00 444
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 68,397.97
IN WITNESS WHEREOF, I do hereunder set my hand this day of August 2010.
STATE OF WYOMING
COUNTY OF LARAMIE
WITNESS my hand and official seal.
LESLIE MILLIKEN NOTARY PUBLIC
COUNTY OF w; STATE OF
LARAMIE 01 WYOMING
MY COMMISSION EXPIRES AUG. 10, 2011
ss.
State of Wyoming,
Department of Health
Of of care Fin
i
Sheila McInerney
Its: TPL /Recovery Coordinator
cing /EqualityCare
C‘0145
This instrument was acknowledged before me o day of August, 2010 by Sheila
McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health, Office of
Healthcare Financing.
Notary Public
My commission expire