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Espy Law Office, P.C.
Hansen Building
2515 Warren Avenue, Suite 501
Cheyenne, WY 82001
:" 00K53; PR P^O 0 I O.
8923h3
RECEIVED
,LINCOLN COt)NTY CLERK
03 I~UG 25 PH 12:1 3
JEANNE WAGNER
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:
Kathleen E. Erickson
3710 St. Hwy 241
Afton, WY 83110
LEGAL DESCRIPTION OF REAL PROPERTY:
Part of Section 33, T35N Rl19W of the 6th P.M., Lincoln County, Wyoming being more
particularly described as follows:
Beginning at a point 1741/2 feet East from a point which is 3 rods East and 2 rods
South from the Northwest corner of Lot 1 of said Section 33 (which comer is known as
the center intersection of the streets running North and South, East and West) and
running thence East 140 feet;
thence South 8 rods;
thence West 1'40 feet;
thence North 8 rods 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 primary vendors providing medical care were Valley Pharmacy, Evanston
Regional Hospital ~and university Surgical Associates in Afton, Wyoming, and
various other prowiders on file with the Department of Health.
DATE OF SERVICE: 5/1/1999 to present
AMOUNT DUE FOR CARE: $ 37,683.32
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH~ FOR ALL CARE: $37,683.32.
IN WITNESS WHEREOF, I do hereun{:ler set my hand this y of August, 2003.
~te of Wyoming, ~~""~
~ D~artment o~! He~l~~
Its:l Recovery Manager ~
STATE Of VVYOMiING )
)
COUNTY OF LARAMIE )
SS.
The foregoing Verified Lien sta~.eme~tJ~or Recipient Name was subscribed and
sworn to before me by Debbie Paiz thls_.~- ~J'~ day of August, 2003.
My commission expires(/~/'~O 0 ~'
WitNESS my hand and official seal.
Notary Pubic