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E S Legal Services, LLC
PO Box 3029
Cheyenne, WY 82003
000133
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: Trudy Merritt
ADDRESS: 277 Dana Street
Thayne, WY 83127
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Beginning at a point which is East along the Quarter Section line 1001.76 feet and
South 7 °25' East, 38.56 feet from the Center of Section 23, Township 34 North, Range
119 West, 6th P.M., Lincoln County, Wyoming, and running thence West 121.67 feet;
thence South 7 °25' East 100.46 feet; thence North 82 °35' East, 120.65 feet; thence
North 7 °25' West 84.75 feet to the point 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:
Star Valley Hospital
Pamida Pharmacy #685
Located in Afton, Wyoming, and various other providers on file with the Department of
Health.
DATE OF SERVICE: 07/01/2010 to present
AMOUNT DUE FOR CARE: 13,848.18
RECEIVED 5/2/2011 at 10:43 AM
RECEIVING 959122
BOOK: 766 PAGE: 133
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 13,848.18
IN WITNESS WHEREOF, I do hereunder set my hand this R of April 2011.
STATE OF WYOMING
COUNTY OF LARAMIE
WITNESS my hand and official seal.
LESLIE MILLIKEN NOTARY PUBLIC
'il�� STATE OF
LARAMIE COUNTY OF er; ;1; WYOMING
MY COMMISSION EXPIRES AUG. 10, 2011
ss.
State of Wyoming,
Department of Health
of
By: Sheila McInerney
Its: TPL /Recovery Coordinator
Notary Public
My commission expires:
000134
ing /EqualityCare
This instrument was acknowledged before me on d ay of April, 2011 by Sheila
McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health, Office of
Healthcare Financing.