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PO Box 3029
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RECEIVED 5/16/2005 at 10:41 AM
RECEIVING # 908413
BOOK: 585 PAGE: 311
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
00311
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:
ADDRESS:
Virginia B. Elmlinger
315 Diamondville Ave.
Diamondville, WY 83116
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
The Lots Numbered Twelve (12), Thirteen (13) and Fourteen (14) of the Block Numbered
Eleven (11) in the Town of Diamondville, Lincoln County, Wyoming, as surveyed, platted
and recorded, together with all improvements and appurtenances thereon.
Subject, however, to all reservations, easements and rights-of-way of record.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were South Lincoln Nursing
Center and South Lincoln Hospital in Kemmerer, Wyoming, and various
other providers on file with the Department of Health.
DATE OF SERVICE: 5/1/200;4 to present
AMOUNT DUE FOR CARE: $38,316.37
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $38,316.37
0~0~4/~ ~~ 0 0 3 i 2
a~._, 2005.
IN WITNESS WHEREOF, I do hereunder set my hand thi day o~f _
State of Wyoming, --'"'"'%~
r'~~-~~t °f Hea~hff~ ~ ~
Its: Recovery Manager 5
STATE OF WYOMING )
) SS.
COUNTY OF LARAMIE )
The foregoing Verified Lien Statement for, Virginia B. Elmlinger was subscribed and
sworn
to
before
me by Debbie Paiz this ~)/'day of, 2005.
WITNESS my hand and official seal.
(,~t~ry Public
My Commission expires: