DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Health Care Financing HCF 13033 (Rev. 11/02) (formerly known as HCF 1075)
STATE OF WISCONSIN Wisconsin Statutes Section 859.07
PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859.07(2), 867.01(3)(d), and 867.02(2)(d). Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. Failure to complete this form is covered under Wisconsin Statutes ss. 859.02 and 865.17. In the Matter of the Estate of: Name of Deceased Social Security Number Date of Death Date of Birth STATE OF WISCONSIN, Circuit Court Branch County Type of Probate File Number Final Date to File Claims
Check here if the Deceased received any of the following:
§ Medicaid benefits under s. 49.46 or 49.47, Wis. Stats.; § Medicaid Community Waiver Program(s) benefits under s. 46.27 through 46.278, Wis. Stats.; § Medicaid or Non-Medicaid Family Care benefits under s. 46.286, Wis. Stats.; § Medicaid Purchase Plan (MAPP) benefits under s. 49.472, Wis. Stats.; § Wisconsin Community Options Program (COP) benefits under s. 46.27, Wis. Stats.; § Wisconsin Chronic Disease Program (WCDP) benefits under s. 49.68 through 49.685, Wis. Stats.
Check here if a predeceased spouse of the Deceased received any of the following and include his/her name and Social Security Number below (if more than one spouse please attach additional sheet):
§ § Wisconsin Community Options Program (COP) benefits under s. 46.27, Wis. Stats.; Wisconsin Chronic Disease Program (WCDP) benefits under s. 49.68 through 49.685, Wis. Stats.
Name of predeceased Spouse
SSN of predeceased Spouse
(Disclosure of Social Security Number of a Medicaid recipient is mandatory per 42 U.S.C. 1320b-7) (Disclosure of Social Security Number of a non-Medicaid recipient is voluntary. The Social Security Number will only be used for the identification of COP and WCDP recipients and for the administration of the Estate Recovery Program)
Name of Personal Representative/Petitioner Name of Attorney
Mailing Address Mailing Address * * * PROOF OF MAILING * * *
being duly sworn on oath certify that on the
mailed via the U.S. Postal Service, by registered or certified mail, a true and correct copy of this Notice to the State of Wisconsin and to the County Clerk of the decedent's county of residence, and I have filed the original Notice with the Register in Probate for the county listed above as required by ss. 859.07, 867.01, and 867.02, Wis. Stats. They have been mailed as follows:
Original to: Register in Probate of county listed above Copy to: STATE OF WISCONSIN Department of Health and Family Services Estate Recovery Program Section P.O. Box 309 Madison, WI 53701-0309 Copy to: COUNTY CLERK of the decedent's county of residence
Subscribed and sworn to before me on Signature Notary Public/Court Official My commission expires