Form 7.0 (A) - Notice To Administrator Of The Medicaid Estate Recovery Program
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1PROBATE COURT OF STARK COUNTY, OHIO
DIXIE PARK, JUDGE
ESTATE OF: _______________________________________________________________
CASE NO. ___________________
NOTICE TO ADMINISTRATOR OF THE
MEDICAID ESTATE RECOVERY PROGRAM
[2117.061 AND 5111.11]
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.
___________________________________________
Signature -
Person responsible for the estate
___________________________________________
Typed or Printed Name
___________________________________________
Address
___________________________________________
City, State, Zip Code
___________________________________________
Telephone Number (include area code)
FORM 7.0 SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF NOTICE
TO ADMINISTRATOR
FORM 7.0 (A) - NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY
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