Clearance Certificate For Public Or Medical Assistance Claim Transfer On Death Deed {10.8.9}

(Top 3 inches reserved for recording data) CLEARANCE CERTIFICATE FOR PUBLIC/MEDICAL ASSISTANCE CLAIM Transfer on Death Deed Minn. Stat. 507.071, subd. 23 DATE: (month/day/year) Minnesota Uniform Conveyancing Blanks Form 10.8.9 (2011) 1. The undersigned is authorized by Minn. Stat. 507.071, subd. 23, and other applicable law, to provide this Clearance Certificate on County, Minnesota behalf of the county agency (as defined in Minn. Stat. 507.071, subd. 1) of ("County Agency"). 2. The real property covered by this Clearance Certificate is located in and is legally described as follows: County, Minnesota, Check here if all or part of the described real property is Registered (Torrens) 3. There is is not a claim or lien that is authorized by the statutes listed in Minn. Stat. 507.071, subd. 3, in favor of the (check only one box) State of Minnesota or the County Agency against the following decedent: Decedent's Full Name Date of Birth Date of Death Amount of Claim Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 10.8.9 4. There is is not a claim or lien that is authorized by the statutes listed in Minn. Stat. 507.071, subd. 3, in favor of the (check only one box) State of Minnesota or the County Agency against the following predeceased spouse(s) of the decedent: Predeceased Spouse(s) Name(s) Date of Birth Date of Death Amount of Claim 5. This Clearance Certificate (check only one box) is not subject to any conditions or restrictions, or is subject to the conditions or restrictions attached hereto. 6. If a claim or lien is noted in paragraphs 3 or 4, contact the following person at the County Agency to arrange for payment and satisfaction of the claim or lien: Name of contact person: Telephone number/ email address: County Agency By: (signature of authorized signer) (name of County Agency) State of Minnesota, County of This instrument was acknowledged before me on (month/day/year) , by , as authorized signer for County, Minnesota. (Stamp) (signature of notarial officer) Title (and Rank): My commission expires: (month/day/year) THIS INSTRUMENT WAS DRAFTED BY: (insert name and address) American LegalNet, Inc. www.FormsWorkFlow.com