HomeMy WebLinkAbout972126Note to Clerk: Please Do Not put 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: State of Wyoming,
Department of Health
Division 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: (HEREINAFTER "DECEDENT):
NAME: Anagene Hepworth
ADDRESS: 89750 Highway 89 RECEIVED 7/22/2013 at 10:37 AM
Grover, WY 83122 RECEIVING 972126
BOOK: 816 PAGE: 172
LEGAL DESCRIPTION OF REAL PROPERTY: JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
County of Lincoln, State of Wyoming
Lot No. 3 of Block No. 7 in the town of Grover, Lincoln County, Wyoming, excepting
there from: Beginning at the Northwest Corner of said Lot and running thence South
113 feet, thence East 124 feet, thence North 113 feet, thence West 124 feet to the
point of beginning, together with the share in the Grover Domestic Water Works,
together with all buildings, improvements, and appurtenances situate thereon and
appertaining thereto, subject to easements, reservations and restrictions and
restrictions of record.
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: January 1, 2007 to present
AMOUNT DUE FOR CARE: $300,438.56
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $300,438.56.
1
0172
THE NAME OF THE PERSON RESPONSIBLE TO PAY THE DEBT SECURED BY THE
LIEN:
IN WITNESS WHEREOF, I do hereunder set my hand this ay of July, 2013.
STATE OF WYOMING
ss.
COUNTY OF LARAMIE
Notary Pu
My Commission expires: 20 t5
2
The estate of the decedent as the term "estate" is defined in Wyo. Stat. Ann. 42 -4-
206 (g)(ii).
WITNESS my hand and official seal.
State of Wyoming,
Department of Health
0173
y: Sheila McInerney
Its: TPL /Recovery Coordinator
This Verified Lien Statement for Lien for Medical Assistance consisting of two pages
was subscribed, sworn to and acknowledged before me on this 1.1 of July, 2013 by
Sheila McInerney as TPL /Recovery Coordinator of the Wyoming Department of Health,
Division of Healthcare Financing.
COUNTY OF
LARAMIE
STATE OF
WYOMING
MY COMMISSION`; EXPIRES MAR. 16, 2015