Amendment To Notice To Commissioner Regarding Possible Claims {70.3.3}

(Top 3 inches reserved for recording data) AMENDMENT TO NOTICE TO COMMISSIONER REGARDING POSSIBLE CLAIMS (UNDER MINN. STAT. 246.53, 256B.15, 256D.16 or 261.04) AFTER CLOSING OF ESTATE Minn. Stat. 524.3-801(d)(4) State of Minnesota County of Minnesota Uniform Conveyancing Blanks Form 70.3.3 (2006) DISTRICT COURT PROBATE DIVISION Judicial District Court File Number In Re: Estate of (Deceased AMENDMENT TO NOTICE TO COMMISSIONER REGARDING POSSIBLE CLAIMS UNDER MINN. STAT. 246.53, 256B.15, 256D.16 OR 261.04 AFTER CLOSING OF ESTATE TO THE COMMISSIONER OF HUMAN SERVICES: 1. Decedent's Full Name(s) Date of Birth Social Security Number 2. The estate served the Commissioner of Human Services with the notice which is being amended on (month/date/year) . 3. An order or decree under Minn. Stat. 524.3-1001 or 524.3-1002, was entered in this estate, or a closing statement under Minn. Stat. 523.3-1003, was filed in this estate on . (month/date/year) 4. My name is in the following described property which was subject to administration by this estate: , and I have an interest Note: This form cannot be recorded independently. It must be attached to Affidavit of Service of Amendment to the Commissioner of Human Services (Form No. 70.3.6 Old Form No. 95-M) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 70.3.3 5. The estate's Notice to the Commissioner is amended as follows: (Check and complete all applicable paragraphs; if paragraph C is checked, supply all items of information for each omitted spouse.) A. Decedent Variations/Other Names Omitted/Corrected Date of Birth Omitted/Corrected Social Security Number B. Predeceased spouse named in notice: Spouse's Name Variations/ Other Names Omitted/Corrected Date of Birth Omitted/Corrected Social Security Number C. Predeceased spouse not named in notice: Name (include all aliases, former names) Date of Birth Social Security Number DATE: (month/day/year) (Name of Person Filing Amendment) Address: Telephone: American LegalNet, Inc. www.FormsWorkflow.com