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Notice To The Commissioner Of Human Services Regarding Possible Claims 70.3.1 - Minnesota
| Notice To The Commissioner Of Human Services Regarding Possible Claims Form. This is a Minnesota form and can be used in Probate Uniform Conveyancing Blanks Department Of Commerce Statewide . |
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(Top 3 inches reserved for recording data) NOTICE TO THE COMMISSIONER OF HUMAN SERVICES REGARDING POSSIBLE CLAIMS (UNDER MINN. STAT. 246.53, 256B.15, 256D.16 or 261.04) Minn. Stat. 524.3-801 State of Minnesota County of Minnesota Uniform Conveyancing Blanks Form 70.3.1 (2011) DISTRICT COURT PROBATE DIVISION Judicial District Court File Number In Re: Estate of (Deceased) NOTICE TO THE COMMISSIONER OF HUMAN SERVICES REGARDING POSSIBLE CLAIMS UNDER MINN. STAT. 246.53, 256B.15, 256D.16 OR 261.04 TO THE COMMISSIONER OF HUMAN SERVICES: 1. Attached and served upon you pursuant to Minn. Stat. 524.3-801(d) is a copy of the (insert title of document) and Notice to Creditors which has been or will be published according to law in the above referenced matter. (INSTRUCTIONS: Include the full name, all aliases and former names of the decedent and spouse(s) in paragraphs 2 and 3 and attach copy of Notice to Creditors.) 2. Decedent's Full Name(s) Date of Birth Social Security Number 3. Predeceased Spouse(s) Name(s) Date of Birth Social Security Number Note: This form cannot be recorded independently. It must be attached to an Affidavit of Service of Notice to the Commissioner of Human Services Regarding Possible Claims (Form No. 70.3.4) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 70.3.1 4. Following a reasonably diligent inquiry, I: have determined the decedent had no predeceased spouse(s). cannot determine the following for the predeceased spouse(s) named below: spouse(s) name full name former names aliases date of birth Social Security number have determined this paragraph does not apply. 5. This notice is given pursuant to Minn. Stat. 524.3-801(d) in case the decedent or a predeceased spouse of decedent might have received assistance for which a claim could be filed under one or more of the following Minnesota Statutes: 246.53, 256B.15, 256D.16 or 261.04. DATE: (month/day/year) (Personal Representative or Attorney for Personal Representative) ATTORNEY for Personal Representative Name: Address: Attorney License No.: Telephone: FAX: American LegalNet, Inc. www.FormsWorkFlow.com
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