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E S Legal Services, LLC
Post Office Box 3029
Cheyenne, WY 82003
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
000514
NAME AND ADDRESS OF PERSON TO WHOM MEDICAL CARE WAS FURNISHED
AND AGAINST WHOSE PROPERTY LIEN IS FILED:
NAME: Cecil and Eva Dabel
ADDRESS: 479 Jackson Street
Afton, WY 83110
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Beginning at a point which is 1 1 /2 rods East and 5 rods North from the
Southwest corner of Lot 4, Block 21 of the Afton Townsite and running thence East
8% rods; thence North 5 rods; thence West 8 1 /2 rods; thence South 5 rods, to the
place of beginning, being a rectangular part of said Lot 4, Block 21, Lincoln County,
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 Care Center
Pamida Pharmacy
Located in Afton, Wyoming and various other providers on file with the
Department of Health.
DATE OF SERVICE: Cecil Dabel: 07/01/2009 to present
Eva Dabel: 07/01/2009 to present
AMOUNT DUE FOR CARE: Cecil Dabel: 61,600.42
Eva Dabel: $167,316.28
1
RECEIVED 5/12/2011 at 10:33 AM
RECEIVING 959235
BOOK: 766 PAGE: 514
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 228,916.70
IN WITNESS WHEREOF, I do hereunder set my hand this day of May 2011.
STATE OF WYOMING
COUNTY OF LARAMIE
WITNESS my hand and official seal.
LESLIE MILLIKEN NOTARY PUBLIC
COUNTY OF STATE OF
LARAMIE LNYOMING
MY COMMISSION EXPIRES AUG 10, 2011
ss.
00 0 5 1S
State of Wyoming,
Department of Health
ice of Healthcare Financing /EqualityCare
d.
LA!
By: Sheila McInern
Its: TPL /Recovery Coordinator
r/
This instrument was acknowledged before me on 3 day of May, 2011 by Sheila
McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health, Office of
Healthcare Financing.
Notary Public
My commission expires: