Certification Of Notice To Administrator Of Medicaid Estate Recovery Program {7.0}

PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK , JUDGE ESTATE OF: _______________________________________________________________ CASE NO. ___________________ CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM [2117.061 AND 5111.11] FORM 7.0 SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF NOTICE TO ADMINISTRATOR The undersigned certifies that a Notice in compliance with Ohio Revised Code 2117.061 and 5111.11 was served upon the following by a method authorized by Civ. R. 73 on the _____ day _____________________, 20_____: Medicaid Estate Recovery 150 E. Gay Street, 21st Floor Columbus, Ohio 43215 ___________________________________ Attorney for Applicant ___________________________________ Typed or Printed Name _______________________________________ Address _______________________________________ City, State, Zip Code _______________________________________ Telephone Number (include area code) Attorney Registration No.__________________ _______________________________________ Person responsible for the estate _______________________________________ Typed or Printed Name ______________________________________ Address _______________________________________ City, State, Zip Code _______________________________________ Telephone Number (include area code) FORM 7.0 - CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY American LegalNet, Inc. www.FormsWorkFlow.com