Form Pw-1780 - Statement Of Claim Request Form
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1STATEMENT OF CLAIM REQUEST FORM
DECEDENT’S NAME:
DECEDENT’S LAST KNOWN ADDRESS:
(Prior to entering nursing home)
(CITY, STATE, ZIP CODE)
DECEDENT’S SOCIAL SECURITY NUMBER:
/
/
DECEDENT’S DATE OF BIRTH:
DECEDENT’S DATE OF DEATH:
GROSS AMOUNT OF DECEDENT’S ESTATE:
(Written documentation must be included)
PERSONAL REPRESENTATIVE’S NAME:
PERSONAL REPRESENTATIVE’S ADDRESS:
(CITY, STATE, ZIP CODE)
PERSONAL REPRESENTATIVE’S
(
)
PHONE NUMBER:
ATTORNEY’S NAME:
ATTORNEY’S ADDRESS:
(CITY, STATE, ZIP CODE)
(
)
ATTORNEY’S PHONE NUMBER:
SEND TO:
DEPARTMENT OF PUBLIC WELFARE
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
P.O. Box 8486
Harrisburg, PA 17105-8486
Estate Recovery Hotline
1-800-528-3708
Facsimile #: (717) 772-6553
PW 1780 - 4/02
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