HomeMy WebLinkAbout963223STATE OF WYOMING
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COUNTY OF LARAMIE
AFFIDAVIT FOR COLLECTION OF CLAIMS OF
CERTAIN CREDITORS OF DECEDENT
PURSUANT TO WYOMING STATUTE 2 -1 -204
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00228
RECEIVED 2/14/2012 at 10:10 AM
RECEIVING 963223
BOOK: 781 PAGE: 228
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, Sheila McInerney, Recovery Manager, State of Wyoming, Department of
Health, Office of Health Care Financing, being first duly sworn, on oath depose and
state that I am making this affidavit pursuant to Wyoming Statute 2 -1 -204, on behalf o f
the State of Wyoming, Department of Health, Office of Medicaid, as a creditor of the
decedent's estate, and that I make the following statements in connection therewith:
1. That Jerry Gray became deceased on 8 -22 -2011, and was a resident of Lincoln
County, State of Wyoming at the time of death; that the decedent died intestate;
that the decedent left no surviving spouse; that the sole and only party entitled to
the estate of the decedent is the Department of Health, Office of Medicaid, as
hereinafter named.
2. That the value of the estate, wherever located, does not exceed $150,000.00.
3. That more than ninety days have elapsed since the death of the decedent.
4. That no application for the appointment of a personal representative of said
decedent is pending or has been granted in any jurisdiction.
5. That to the best of my knowledge no affidavit pursuant to Wyoming Statute 2 -1-
201, in connection with the decedent, has been presented to any party identified
in that section.
6. This creditor's claim is presented on the following facts:
a. That Jerry Gray received medical assistance pursuant to Title XIX of the
Social Security Act, as amended, and the Wyoming Medical Assistance
and Services Act, as amended, in the amount of Four Thousand Eight
Hundred Thirty -One Dollars and Sixty -One Cents ($4,831.61), such care
being provided by Lincoln County Public Health Nurse and Star Valley
Hospital in Afton, Wyoming and by other providers on file with the
Department of Health.
b. That Jerry Gray was a "recipient" as defined by applicable Medicaid law.
c. That Jerry Gray was age fifty -five (55) or older when he received
$4,831.61 of such reimbursable medical assistance for nursing facility
services, home and community -based services, related hospital and
prescription drug services, and any items under the Wyoming State Plan.
That Jerry Gray was an inpatient in a nursing facility, intermediate care
facility, or other medical institution when he /she received $4,831.61 of
such reimbursable medical assistance.
7. That by presentation of this affidavit, the State of Wyoming, Department of
Medicaid:
a. Waives any immunity from suit or levy of execution it might otherwise
have;
b. Agrees to indemnify and hold harmless from all claims whatsoever any
party delivering assets on the basis of such affidavit, to the extent of the
full value of the assets so delivered; and,
c. Agrees to be answerable and accountable to a personal representative of
the estate, if appointed, or to any other person or party having a superior
right.
8. That the following named creditor is the sole and only party entitled to the estate
of the decedent, that there are no other distributees of the decedent having a
right to succeed to any of the property of the decedent under probate
proceedings, and that therefore the following named claiming creditor is entitled
to payment or decedent's property: Wyoming Department of Health, Office of
Health Care Financing.
9. That the original of this affidavit is being filed of record with the County Clerk of
Lincoln County, Wyoming, in accordance with Wyoming Statutes 2- 1- 204(b)
and 2- 1- 201(c), as amended.
Executed at Cheyenne, Wyoming, this day of
STATE OF WYOMING
DEPARTMENT OF HF_.AE.TH
OFFICE OF HEALTH CARE FINANCING
Signed: q'_
By Sheila McInerney
Recovery Manager
Wyoming Office of Medicaid
6101 Yellowstone Road, Suite 210
Cheyenne, Wyoming 82002
(307) 777 -7531
Subscribed and sworn to before me by Sheila McInerney, Recovery Manager, for
the State of Wyoming, Department of Health, Office of Health Care Financing, this
day of T i, 20 0-
My commission expires:
WITNESS my hand and official seal.
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NOTAIRfr PUBLIC
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20
hyAnn Bausch Notary Public
County of t iFa'N W Wyoming
Laramie
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My Commission Expires July 5, 2015
00229