ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY TELEPHONE NUMBER: FAX NO. (Optional): EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1035 Palm Street, Room 385 Same as above San Luis Obispo, CA 93408 San Luis Obispo Division ESTATE OF: CASE NUMBER: NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code §§ 215, 9202 (a), 19202 1. You are hereby given notice of administration of the estate of the following person: a. Decedent's Name:_____________________________________________________________. b. Date of Death:________________________________________________________________. c. Social Security Number:_________________________________________________________. 2. A copy of the decedent's death certificate is attached. 3. 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. 4. The decedent: a. b. Did not have a predeceased spouse or registered domestic partner (or) Did have a predeceased spouse or registered domestic partner, a copy of whose death certificate is attached. Page 1 of 3 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR022 Rev. 1/1/15 NOTICE TO DEPT OF HEALTH CARE SERVICES Probate Code §§ 215. 9202(a) and 19202 Probate Code §§ 215. 9202(a) and 19202 American LegalNet, Inc. www.FormsWorkFlow.com Insert case name: CASE NUMBER 5. The party providing you with this notice is as follows: a. Name:_______________________________________________________________________. b. Address:_____________________________________________________________________. c. Telephone:___________________________________________________________________. Estate Attorney Personal Representative Beneficiary/ Heir Trustee d. Capacity: Person in Possession of the Property of Decedent. 6. If you have a claim against the above mentioned estate, please forward documentation to the address indicated in item 5 above. Date:_____________________ ____________________________________________ (Signature of party providing notice) Page 2 of 3 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR022 Rev. 1/1/15 NOTICE TO DEPT OF HEALTH CARE SERVICES Probate Code §§ 215. 9202(a) and 19202 Probate Code §§ 215. 9202(a) and 19202 American LegalNet, Inc. www.FormsWorkFlow.com Insert case name: CASE NUMBER PROOF OF SERVICE 1. I am over the age of 18 and am not a party to this case. I live or work in the county where the mailing occurred. 2. My (the servers) home or business address is as follows: 3. I served the foregoing 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 4720 Sacramento, California 95899-7425 4. Date mailed: _______________, Place mailed (city, state): ________________________ . I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. _________________ ________________________________ ___________________________ (Date signed) (Type or Print Name) (Signature) Page 3 of 3 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR022 Rev. 1/1/15 NOTICE TO DEPT OF HEALTH CARE SERVICES Probate Code §§ 215. 9202(a) and 19202 Probate Code §§ 215. 9202(a) and 19202 American LegalNet, Inc. www.FormsWorkFlow.com