HomeMy WebLinkAbout966602Note to Clerk: Please Do Not out recording Information Above this Line.
When Recorded, return to:
Office of the Attorney General
123 State Capitol
Cheyenne, WY 82002
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT:
NAME: Betty Hoffman
ADDRESS: 908 Cedar Ave.
Kemmerer WY 83101
State of Wyoming,
Department of Health
Division of Healthcare Financing /EqualityCare
ADDRESS: 6101 Yellowstone Road, Suite 210
Cheyenne, Wyoming 82002
0020
NAME AND ADDRESS OF PERSON TO WHOM MEDICAL CARE WAS FURNISHED
AND AGAINST WHOSE PROPERTY LIEN IS FILED: (HEREINAFTER "DECEDENT):
LEGAL DESCRIPTION OF REAL PROPERTY:
The northerly fifty feet of the lot numbered one, of the block numbered nine, in
the Town of Kemmerer, in the County of Lincoln, in the State of Wyoming, as
surveyed, platted and recorded, and more particularly described as follows, to-
wit: Beginning at the northwesterly corner of said lot one, running thence
northerly along the northerly line of said lot one, distance of one hundred forty
feet, to the westerly alley line of said block nine, thence at right angles, southerly
along said alley line fifty feet, thence at right angles westerly one hundred forty
feet to the westerly boundary line of said lot one on Cedar Avenue, thence at
right angles along said boundary line on Cedar Avenue, fifty feet to the point of
beginning, being a rectangular tract of ground fronting fifty feet on Cedar Avenue
and extending to the alley of said block nine, one hundred forty feet, together
with all improvements situate thereon and all easements and appurtenances
belonging thereto.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The vendors providing medical care are on file with the Department of Health and
available to the decedent's personal representative upon signing a HIPAA-
compliant authorization to release medical information.
DATE OF SERVICE: 05/01/2009 to present
AMOUNT DUE FOR CARE: $53,361.56
RECEIVED 9/4/201 at 12:01 PM
RECEIVING 966602
BOOK: 793 PAGE: 204
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: $53,361.56.
THE NAME OF THE PERSON RESPONSIBLE TO PAY THE DEBT SECURED BY
THE LIEN:
The estate of the decedent as the term "estate" is defined in Wyo. Stat. Ann.
42 -4 -206 (g)(ii).
IN WITNESS WHEREOF, I do hereunder set my hand this —gay of August, 2012
STATE OF WYOMING
COUNTY OF LARAMIE
ss.
WITNESS my hand and official seal.
State of Wyoming,
Department of Health
y: Sheila McInerney
Its: TPL /Recovery Coordinator
This Verified Lien Statement for Lien for Medical Assistance consisting of
pages was subscribed, sworn to and acknowledged before me on thiscW day of
August, 2012 by Sheila McInerney as TPL /Recovery Coordinator of the Wyoming
Department of Health, Division of Healthcare Financing.
0020F)
My Commission expires: 01lay113