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When Recorded Return to:
E S Legal Services, LLC
Post Office Box 3029
Cheyenne, WY 82003
RELEASE OF VERIFIED LIEN STATEMENT
Claimant, State of Wyoming, Department of Health, Office of Medicaid located at 2300
Capitol Avenue, Room 147, Cheyenne, Wyoming 82002, hereby releases the VERIFIED
LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE which was recorded on
September 3, 2010, at Book 753, Page 144, as Document No. 955311, on property owned
by Agnes Guyette and affecting the lands described as:
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.
The above described lien is fully released as to the above described real property,
but Claimant expressly retains and reserves the right to satisfy the remaining debt due and
owing Claimant from any and all other available assets.
Notwithstanding any other provision in this Release of Verified Lien Statement,
Claimant is not releasing or waiving any rights it has or may have to satisfy the remaining
unpaid debt from any and all other assets, including past, present, and future assets,
owned by or in which the Estate of Agnes Guyette has an interest.
IN WITNESS WHEREOF, I do hereunder set my hand this ,R ay of January,
2011.
RECEIVED 3/1/2011 at 11:19 AM
RECEIVING 958295
BOOK: 763 PAGE: 222
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
STATE OF WYOMING
ss.
COUNTY OF LARAMIE
State of Wyoming,
Department of Health
Sheila McInerney
Its: TPL /Recovery Coordinator
Notary Public
My Commission expires:
00•222
tA4
This instrument was acknowledged before me on day of January, 2011 by
Sheila McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health,
Office,pt Meal hcare Financing.
O hand official seal.
M 114 t 1