Affidavit Of Notice To TennCare {165}

IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE IN THE MATTER OF THE ESTATE OF AFFIDAVIT OF NOTICE TO TENNCARE PART 2 FILE N0. PROBATE DIVISION DECEASED STATE OF TENNESSEE HAMILTON COUNTY } PURSUANT TO T.C.A. §§ 30-2-301(b)(5), 71-5-116(d)(1)(B), Affiant, being duly sworn, deposes as follows. 1. I am the duly qualified personal representative of the captioned estate. 2. I have personal knowledge of the matters herein stated. 3. As the decedent was 55 years or older at time of death, I verily affirm that on the ___________ day of _________________, 20___, I provided to the Bureau of TennCare the TENNCARE ELIGIBILITY VERIFICATION/REQUEST FOR RELEASE OF ESTATE RECOVERY COST CLAIM (TC-0087), as required by T.C.A. § 71-5-116(d)(1)(B). _____________________________________ Affiant Sworn to and subscribed before me this ____ day of ______________, 20___. _____________________________________ Notary Public My Commission Expires: ____________________. - 1 of 1 Form 165, Rev. 2008.09.18 American LegalNet, Inc. www.FormsWorkFlow.com