Certification Of Notice To Administrator Of Medicaid Estate Recovery Program {7.0}

PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge ESTATE OF CASE NO. , DECEASED CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM [R.C. 2117.061 AND 5162.21] THIS FORM SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF NOTICE TO ADMINISTRATOR The undersigned certifies that a Notice in compliance with Ohio Revised Code 2117.061 and 5162.21 was served upon the following by a method authorized by Civ.R. 73 on the 20 : Medicaid Estate Recovery 150 E. Gay Street, 21st Floor Columbus, Ohio 43215 _ day of , Attorney for Applicant Person Responsible for the Estate Typed or Printed Name Typed or Printed Name Address Address City, State, Zip Code City, State, Zip Code Telephone Number (include area code) Attorney Registration No. Telephone Number (include area code) FORM 7.0 ­ CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM Amended: June 1, 2014 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com