HomeMy WebLinkAbout974584Note 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
NAME OF CLAIMANT:
ADDRESS: 6101 Yellowstone Road, Suite 210
Cheyenne, Wyoming 82002
NAME: Neal Kennington and Ireta Kennington
ADDRESS: 45 Allred Road
Afton WY 83110
SUBJECT to all rights -of -way
SUBJECT to all rights -of -way
RECEIVED 12/16/2013 at 2:24 PM
RECEIVING 974584
BOOK: 825 PAGE: 342
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
State of Wyoming,
Department of Health
Division of Healthcare Financing /EqualityCare
04`2
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:
PARCEL 1:
East Half Northwest Quarter and South Half Southeast Quarter, Section 26,
Township 32 North, Range 119 West, and West 1 rod of North Half Southeast
Quarter, and a tract of land described as follows: Beginning at the center of said
Section 26, thence East 16 1 /2 feet, thence Northwesterly to a point 65 feet North
of the center of said Section 26; thence South 65 feet to the point of beginning.
PARCEL 2:
Beginning at a point which is the center of Section 26, Township 32 North, Range
119 West 6 P.M., Wyoming, and running thence East 1 rod, thence South 80
rods, thence West 1 rod, thence North 80 rods, to the point of beginning. The
above described tract being a lane 1 rod wide extending across the West side of
North Half Southeast Quarter of Section 26.
PARCEL 3:
Commencing at the center of Section 26, Township 32 North, Range 119 West,
and running thence East 16 feet, thence Northwest to a point which is 65 feet
North of the center of said Section 26, (the place of beginning), thence South 65
feet to the said point of beginning, being a triangular piece of land, part
Southwest Quarter Northeast Quarter of said Section, Township and Range.
SUBJECT to all rights -of -way
Less and excepting therefrom:
Beginning at the Southeast corner of Section 26, Township 32 North, Range 119
West, 6 P.M., Wyoming and running thence West, along the South boundary
line of said Section 26, 240 feet, thence North, on a line parallel to the East
boundary line of said Section 26, 185 feet, thence East, on a line parallel to the
South boundary line of said Section, 240 feet, more or Tess, to the East boundary
line of said Section, thence South, along said East boundary line, 185 feet, more
or Tess, 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 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: Neal Kennington 02/01/2011 to present
Ireta Kennington 02/01/2011 to present
AMOUNT DUE FOR CARE: Neal Kennington 67,757.74
Ireta Kennington 169,836.11
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 237,593.85.
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 I1*- day of December,
2013
State of Wyoming,
Department of Health
tA
y: Sheila McInerney
Its: TPL /Recovery Coordinator
C 43
STATE OF WYOMING
COUNTY OF LARAMIE
This Verified Lien Statement for Lien for Medical Assistance consisting of c2.
pages was subscribed, sworn to and acknowledged before me on this 1\ D-day of
December, 2013 by Sheila McInerney as TPL /Recovery Coordinator of the Wyoming
Department of Health, Division of Healthcare Financing.
WITNESS my hand and official seal.
9AR3ARA A, ROLL
COUNTY OF
LARANOS
SSION
ss.
G s44
My Commission expires: itmir'ZZO