COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGEJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)ESTATE OF , DECEASEDCASE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM [R.C. 2117.06]THE PEOPLE OF THE STATE OF NEW YORK TOThe undersigned gives notice to the Administrator of the Estate Recovery Program that the decedent was fifty-five (55) years of age or older at the time of death and has been determined to have been a recipient of medical assistance under Chapter 5111 of the Revised Code.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomExecutorAdministratorCommissionerPerson who filed pursuant to 2113.03 of the Revised Code for release from administration.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,CERTIFICATE OF SERVICE(Attorney must sign above and type name below)This is to certify a true copy of the above notice was served by certified U.S. mail, postage prepaid to the Administrator of the Estate Recovery Program, on.Attorney(s) forPerson Responsible for the EstateOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:«Ftu8/1£-Mobile Tel. No.:Eff. Date: -/-/-FORM 7.0 NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAMAmerican LegalNet, Inc. www.USCourtForms.com
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