HomeMy WebLinkAbout979449Note 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:
979449 11/24/2014 10:22 AM
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 843 PAGE: 787 LIEN STATEMENT
JEANNE WAGNER LINCOLN COUNTY CLERK
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AMENDED VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
(Amending Verified Lien Statement recorded 10/21/2013 at Book 822, Page 565)
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: Joyce Ann Dayton
ADDRESS: 320 East Main Street
Cokeville WY 83114
LEGAL DESCRIPTION OF REAL PROPERTY:
A IA 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: 125,434.70
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 125,434.70.
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 of November,
2014
STATE OF WYOMING
COUNTY OF LARAMIE
ss.
WITNESS my hand and official sea
JESSICA L. BALDWIN NOTARY PUBLIC
COUNTY OF
LARAMIE
MY COMMISSION E 'IRES
STATE OF
WYOMING
State of Wyoming,
epaqment of ealtl'
Sheila McInerney
Its: TPL /Recovery Coordinator
This Verified Lien Statement for Lien for Medical Assistance consisting of o2
pages was subscribed, sworn to and acknowledged before me on this l day of
November, 2014 by Sheila McInerney as TPL /Recovery Coordinator of the Wyoming
Department of Health, Division of Healthcare Financing.
No'ary Public
My Commission expires: