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

PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE ESTATE OF: CASE NO. NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM [R.C. 2117.061 AND 5162.21] IF THE ESTATE OF THE DECEDENT IS SUBJECT TO THE MEDICAID ESTATE RECOVERY PROGRAM PURSUANT TO R.C. 5162.21, THIS NOTICE SHALL BE FILED WITH THE ADMINISTRATOR OF THE PROGRAM AT THE FOLLOWING ADDRESS: Medicaid Estate Recovery 150 E. Gay Street, 21st Floor Columbus, Ohio 43215 THIS NOTICE IS NOT A PUBLIC RECORD AND SHALL NOT BE FILED IN THE PROBATE COURT The undersigned person responsible for the estate hereby states the following: 1. 2. Name of Decedent:_ Address of Decedent: 3. 4. 5. 6. Date of Birth: Date of Death: Social Security Number: Check all applicable boxes: Age: A copy of the Schedule of Assets (Form 6.1) or Assets and Liabilities (Form 5.1) is attached; A schedule of any other real and personal property and other assets in which the decedent had any legal title or interest at the time of death (to the extent of the interest), including assets conveyed to a survivor, heir, or assign of the individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement; The spouse of the decedent was subject to the Medicaid estate recovery program, a separate notice is being submitted for the pre-deceased spouse. FORM 7.0(A) ­ NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE Effective Date: June 1, 2014 American LegalNet, Inc. www.FormsWorkFlow.com Signature - Person Responsible for the Estate Typed or Printed Name Address City, State, Zip Telephone Number (include area code) Print Form Reset Form FORM 7.0(A) ­ NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE Effective Date: June 1, 2014 American LegalNet, Inc. www.FormsWorkFlow.com