HomeMy WebLinkAbout900785When Recorded
Relurn
Espy & Shuck
Hansen Building
2515Warren Avenue Suite 501
Cheyenne, WY 82001
REOE IVE[)
LINO.,0L.I'J C011i',JT'¢ CLERK
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT: State of Wyoming, Department of Health, Office of Medicaid
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:
NAME: Daniel D. Auilman
ADDRESS: 82 Lazy Box J Ranch Co Rd.
Lincoln County, WY 83127
LEGAL DESCRIPTION OF- REAL PROPERTY:
AN UNDIVIDED ONE-HALF INTEREST IN:
Beginning at the Southwest Corner of the El/2 El/2 NWl/4 of Section 25,
T34N, Rl19W, 6th:P.M., Wyoming, and running thence North, along the
West Boundary of s:aid El/2 El/2 NW 1/4,466.69 feet, thence East 466.69
feet, thence South 466.69 feet, more of less, to the South Boundary of said
El/2 El/2 NW 1/4, 'thence West, along said South Boundary, 466.69 feet,
more or less, to the point of beginning. 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 Star Valley Hospital,
Easter Idaho Health Service and Medical Imaging Association in Wyoming
and Idaho and various other providers on file with the Department of Health.
DATE OF SERVICE: November 1,2003 to present
AMOUNT DUE FOR CARE: $33,707.22
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $33,707.22.
THIS SECTION INTENTIONALLY LEFT BLANK
.,,. 888
IN WITNESS WHEREOF, I do .hereUnder set my hand this,~ YT~ay of June,
2004.
itY°ming, ~'%
Its.?-Re~very Manager
STATE OF WYOMING
COUNTY OF LARAMIE
The foregoing Verified Lien Statement,~'or Daniel D. Aullman was subscribed and
sworn to before me by Debbie Paiz this :.~D day of June, 2004.
WITNESS my hand and official seal.
Notary Public
My Commission expires: