HomeMy WebLinkAbout877046 VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL
NAME OF CLAIMANT: State of Wyoming, Department of Health.
ADDRESS: 117 Hathaway Building
Cheyenne, Wyoming 82002
NAME AND ADDRESS OF PERSO~ TO WHOM MEDICAL CARE WAS FURNISHED AND
AGAINST WHOSE PROPERTY LIEN IS FILE:
NAME: ELSIE RATLIFF
ADDRESS: 77 CIRCLE DRIVE
AFTON, WY 83110
LEGAL DESCRIPTION OF REAL PROPERTY:
Lot 13 of Westview Village Subdivision, Lincoln County,
Wyoming as described on the official plat therof.
Together with all improvements situate thereon and all easements
and appurtenances belonging thereto. Quit Claim Deed recorded
March 3, 1987 in Book 248PR on page 587 of Lincoln County public
records.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were Star Valley
Senior Citizens, Valley Pharmacy, Kemmerer Senior Center
and Star Valley Hospital in Afton, Wyoming', and various
other providers on file with the Department of Health.
DATE OF SERVICE:.ll/01/1999 to present
AMOUNT DUE FOR CARE: $ 24,655.54
TOTAL AMOUNT DUE ~D OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $ 24,655.54.
~ IN WITNESS WHEREOF, I do hereunder set my hand thi~~
day
of October, 2001.
~epartmebt of Healt~
Its: Recovery Manager
STATE OF WYOMING )
) ss.
COUNTY OF LARAMIE )
The foregoing Verified Lien Statement for Lien for Medical
'Assistance of ELSIE RATL~FF was subscribed and sworn to before me
by Debbie Paiz this~ day of October, 2001.
WITNESS my hand and official seal.
'~--Notary Publ'
My commission expires :~{~p ~ a.{~i~