Ohio Probate Form - Notice To Administrator Of Medicaid Estate Recovery Program
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1
2PROBATE COURT OF _____________ COUNTY, OHIO
________________, 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.
Name of Decedent:____________________________________________________________________
2.
Address of Decedent:__________________________________________________________________
____________________________________________________________________________________
3.
Date of Birth:__________________________________________________ Age: __________________
4.
Date of Death:________________________________________________________________________
5.
Social Security Number:________________________________________________________________
6.
Check all applicable boxes:
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 RECOVERY
Effective Date: June 1, 2014
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