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PO Box 3029
Cheyenne, WY 82003
RECEIVED 5/16/2005 at 11:18 AM
RECEIVING # 908423
BOOK: 585 PAGE: 358
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
0 0:3 5 8
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:
Nelda L. Schwab
519 Madison
Afton, WY 83110
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Beginning at the point which is 5 rods South of the Northwest Corner of the Lot Number 2,
Block Number 26, of the Afton Townsite Suvey, and running thence South 3 rods; thence
East 8 rods; Thence North 3 rods; thence West 8 rods to the place of beginning.
Containing 24 Square rods of land. 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 Legacy Homes Assisted
Living, Family Pharmacy, and Star Valley Medical in Afton, Wyoming, and
various other providers on file with the Department of Health.
DATE OF SERVICE: 9/1/2002 to present
AMOUNT DUE FOR CARE: $45,762.38
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING, DEPARTMENT
OF HEALTH, FOR ALL CARE: $45,762.38
IN WITNESS WHEREOF, I do hereunder set my hand this~C~ay of May, 2005.
State of Wyoming,
Department of Health
STATE OF WYOMING )
.) SS·
COUNTY OF LARAMIE )
The foregoing Verified Lien Statement for Nelda L. Schwab was subscribed and
sworn to before me by Debbie Paiz this~-~ day of May, 2005.
WITNESS my hand and official seal·
My Commission expires: