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Statement Of Claim Request Form - Pennsylvania

Statement Of Claim Request Form Form. This is a Pennsylvania form and can be used in Department Of Public Welfare Statewide .
 Fillable pdf Last Modified 2/15/2007
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STATEMENT 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 American LegalNet, Inc. www.FormsWorkflow.com
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