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Espy Law Office, P.C.
Hansen Building 51 ? 443
2515 Warren Avenue, Su~'e(-"5~K PR PAGF_..
Cheyenne, WY 82001
RECEIVED
LINCO,~.I,, COtlNTY CLERK
, ' cF;?:~": "'" "'''':
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT: State of Wyoming, Department of Health, Office of Medicaid
ADDRESS: 2300 Capitol Avenue, Room 147
Cheyenne, Wyoming 82002
NAME AND ADDRESS OF PERSON TO WHOM MEDICAL CARE WAS FURNISHED
AND AGAINST WHOSE PROPERTY LIEN IS FILED:
NAME:
ADDRESS:
Florence Sudonik
21 Frontier
Diamondville, WY 83116
LEGAL DESCRIPTION OF REAL PROPERTY:
The East ~ of Parcel 37 of the Town of Diamondville, Lincoln County,
Wyoming as described on the official plat thereof.
Also the West ½ of Lot 10 of Block 21 of the Town of Diamondville, Lincoln
County, Wyoming as described on the official plat thereof.
Together with all improvements thereon, and easements, appurtenances and
incidents belonging and apPertaining thereto.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were South Lincoln Nursing
Facility in Kemmerer, Wyoming and Rock Springs I.V. Center in Rock
Springs, Wyoming and various other providers on file with the Department of
Health.
DATE OF SERVICE: 10/01/2000 to present
AMOUNT DUE FOR CARE: $22,455.93
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $22,455.93.
THIS SECTION INTENTIONALLY LEFT BLANK
IN WITNESS WHEREOF, I do hereunder set my hand this ~,¢.~ day of April, 2003.
State of Wyoming,
Department of Health
v iBt~bvieeryP~nagerV - _.~
STATE OF WYOMING )
) SS.
COUNTY OF LARAMIE )
' The foregoing Verified Lien Statement for Florence Sudonik was subscribed and
sworn to before me by Debbie Paiz this (~ ¢--,& day of April, 2003.
WITNESS my hand and official seal.
My cOmmission expires: /~2/~ ,~.~
Notary Public