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E S Legal Services, LLC
PO Box 3029
Cheyenne, WY 82003
RECEIVED 2/8/2012 at 9:22 AM
RECEIVING 963116
BOOK: 781 PAGE: 53
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT:
State of Wyoming
Department of Health
Division of Healthcare Financing /Medicaid
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: Frances Gordes
ADDRESS: 614 Cedar Avenue
Kemmerer, WY 83101
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
A 1/3 interest in That part of Lot 4 of Block 6 of the Town of Kemmerer described as
follows: Beginning at a point 100 feet Southerly from the Northwest corner of said
Block 6 and running thence Southerly on Cedar Avenue 40 feet; thence Easterly 140
feet; thence Northerly 40 feet; thence Westerly 140 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:
South Lincoln Nursing Center
South Lincoln Hospital District
Located in Kemmerer, Wyoming, and various other providers on file with the
Department of Health.
DATE OF SERVICE: 05/01/2011 to present
AMOUNT DUE FOR CARE: 18,067.27
00053
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 18,067.27
IN WITNESS WHEREOF, I do hereunder set my hand this c°3-' ='day of January 2012.
STATE OF WYOMING
COUNTY OF LARAMIE
WITNESS my hand and official seal.
LESUE MIWKEN NOTARY PUBLIC
COUNTY OF
LARAMIE
STATE OF
WYOMING
MY COMMISSION EXPIRES AUGUST 10, 2015
ss.
State of Wyoming,
Department of Health
Division of Healthcare Financing /Medicaid
By Sheila McInerney
Its: TPL /Recovery Coordinator
Notary
My commission expires:
00054
2
(c
This instrument was acknowledged before me on J-3 day of January, 2012 by Sheila
McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health, Division of
Healthcare Financing.