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Notice To Department Of Health Care Services RI-PR036 - California
| Notice To Department Of Health Care Services Form. This is a California form and can be used in Probate Riverside Local County . |
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE PALM SPRINGS 3255 E. Tahquitz Canyon Way, Palm Springs, CA 92262 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) RIVERSIDE 4050 Main St., Riverside, CA 92501 RI-PR036 FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): IN THE MATTER OF: CASE NUMBER: Hearing Date: Time: Department: NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code §§ 215, 9202(a), 19202 1. You are hereby given notice of the death of the following person: a. b. c. 2. 3. Decedent's Name: Date of Death: Social Security Number: A copy of the decedent's Death Certificate is attached. The decedent received or may have received health care under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or had a predeceased spouse or registered domestic partner who received or may have received health care. a. b. The decedent did not have a predeceased spouse or registered domestic partner (or) The decedent did have a predeceased spouse or registered domestic partner, a copy of whose death certificate is attached. Name: Address: Telephone: Capacity: Estate Attorney Beneficiary Personal Representative Trustee Person in Possession of Property of the Decedent 4. 5. The party providing you with this notice is as follows: a. b. c. d. 6. This notice is being provided by a general personal representative, trustee, or the attorney who represents a general personal representative or trustee. If you have a claim against the above-mentioned estate or trust please forward documentation to the address indicated in item 5 above within the period provided in Probate Code 9202(a) or 19202(b). (PARTY PROVIDING NOTICE) Date: Approved for Optional Use Riverside Superior Court RI-PR036 [Rev. 3/22/13] NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code § 215, 9202(a), 19202 Probate Code §§ 215, 9202(a), 19202 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 IN THE MATTER OF: CASE NUMBER: PROOF OF SERVICE BY MAIL 1. I am over the age of 18 and am not a party in this cause. I am a resident of or employed in the county where the mailing occurred. My (the servers) home or business address is: 2. (STREET ADDRESS) (CITY, STATE, ZIP) 3. I served the forgoing NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES by enclosing a copy in an envelope addressed to: Department of Health Care Services Estate Recovery Unit P.O. Box 997425, MS 7425 Sacramento, CA 95899-7425 and depositing the sealed envelope with the United States Postal Service with the postage fully prepaid. 4. Date mailed: , Place mailed (city, state): Date: (SIGNATURE OF DECLARANT) Page 2 of 2 Approved for Optional Use Riverside Superior Court RI-PR036 [Rev. 3/22/13] NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code § 215, 9202(a), 19202 Probate Code §§ 215, 9202(a), 19202 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com
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