Free Microsoft Word - Decedents Estate Series 1-13.7.DOC - Ohio

PROBATE COURT OF _____________ COUNTY, OHIO
ESTATE OF ________________________________________________, DECEASED CASE NO. _______________________

NOTICE OF ADMINISTRATOR OF ESTATE RECOVERY PROGRAM
[R.C. 2117.061] The undersigned gives notice to the Administrator of the Estate Recovery Program that the decedent was fifty-five (55) years of age or older at the time of death and has been determined to have been a recipient of medical assistance under Chapter 5111 of the Revised Code. ____________________________________ Executor Administrator Commissioner Person who filed pursuant to 2113.03 of the Revised Code for release from administration.

CERTIFICATE OF SERVICE
This is to certify a true copy of the above notice was served by certified U.S. mail, postage prepaid to the Administrator of the Estate Recovery Program, on the __________ day of ______________, 20______. ____________________________________ Person Responsible for the Estate ____________________________________ Typed or Printed Name ____________________________________ Address ____________________________________ City, State, Zip ____________________________________ Phone Number (include area code)

FORM 7.0 ­ NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM

4/8/04