HomeMy WebLinkAbout973783Note 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):
RECEIVED 10/21/2013 at 10:47 AM
NAME: Joyce Ann Dayton RECEIVING 973783
ADDRESS: 320 East Main Street BOOK: 822 PAGE: 565
Cokeville WY 83114 JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
LEGAL DESCRIPTION OF REAL PROPERTY:
A 1 /2 interest in The East 1 /2 of Lot 3 and the West 87.28 feet of Lot 4 in the Stoner
Kinney First Addition of Block Number 1 in the Town of Cokeville, Lincoln
County, Wyoming, as surveyed platted and recorded, 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: 11/01/2008 to present
AMOUNT DUE FOR CARE: $132,696.13
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: $132,696.13.
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).
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IN WITNESS WHEREOF, I do hereunder set my hand this
WITNESS my hand and official seal.
State of Wyoming,
Department of Health
Sheila c nerney
Its: TPL /Recovery Coordinator
ay of October, 20143 6 6
STATE OF WYOMING
ss.
COUNTY OF LARAMIE
This Verified Lien Statement for Lien for Medical Assistance consisting of a-
pages was subscribed, sworn to and acknowledged before me on this day of
October, 2013 by Sheila McInerney as TPL /Recovery Coordinator of the Wyoming
Department of Health, Division of Healthcare Financing.
No ary Public
My Commission expires: 1u. vtiti 2
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