Free Instructions - New Hampshire

Instructions for completing Affidavit of Nursing Home Administrator
(NHJB-2147-P) Form use. This form is used for the disposition of patient nursing home accounts when conditions specified in RSA 151-A:15 are met. Top part of form ·COURT NAME: Enter the name of the county probate court where the document will be filed. (example: Belknap County Probate Court; Rockingham County Probate Court). ·CASE NAME: Enter the name of the deceased (example: Estate of John Adams; Estate of Susan Jones). ·CASE NUMBER: Leave blank if not yet assigned by court OR fill in case number if it is known.

Numbered part of form 1. 2. Enter your name as Administrator, the name, complete address and telephone number of the nursing home. Enter the name of the decedent, his/her Medicaid number and social security number on the appropriate lines provided. Enter the date of admission of the deceased resident and the date of death. In the space provided, list all contacts of the deceased resident, of which you are aware, including the name, address, telephone number and relationship to the decedent. Check off one box to indicate according to nursing home records if a will exists for the decedent and if one does exist it is either attached to this form or the name of the person holding the will is entered on the line provided and listed in item #4 of this form. You are verifying that to the best of your knowledge no one has opened an estate for the decedent in the county where the decedent last resided. No entry is required for this item. Enter the total amount of the gross value of the decedent's personal property remaining at the nursing home, not to exceed $2,500, on the appropriate line provided. List all known debts of decedent by entering the amount for each debt on the line provided. Attach additional sheets of paper as needed. You are certifying that you have sent copies of this affidavit to the Dept. of Revenue Administration, Department of Health & Human Services, and all known heirs and legatees as listed in item 4. You are requesting the Court give you authorization to pay all debts of the deceased according to statutory priorities and to pay remaining funds into the treasury of the county of the deceased's residence in accordance with the statute noted. No entry is required for this item.

3. 4.

5.

6.

7.

8.

9.

10.

NHJB-2147-P Instructions (06/26/2007)

Page 1 of 2

Signature section This form must be signed in the presence of a Notary Public or Justice of the Peace. They will complete the section immediately following your signature. You will sign the form on the Nursing Home Administrator Signature line, and date it in the appropriate space to the left.

Order This section will be completed by the judge once the document is filed with the court and reviewed in detail by the judge.

Review the completed form for accuracy prior to filing it with the court. If completing this form on-line, some fields may be filled in automatically based on entries in other fields. If more space is needed for any question, please attach additional sheets of paper.

NHJB-2147-P Instructions (06/26/2007)

Page 2 of 2