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 VICTIM COMPENSATION & GOVERNMENT CLAIMS BOARD Probate Code § 9202 (b) 1. You are hereby given notice of the death 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. At the time of the decedent's death or during administration of the decedent's estate, the following heirs or beneficiaries of the decedent's estate were incarcerated in a facility identified in Probate Code § 216 or § 9202(b): Name Location of Incarceration Date of Birth CDCR or Booking Number Page 1 of 3 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR023 Rev. 1/1/15 NOTICE TO VICTIM COMPENSATION & GOVERNMENT CLAIMS BOARD Probate Code § 9202(B) Probate Code § 9202 (b) American LegalNet, Inc. www.FormsWorkFlow.com Insert case name: CASE NUMBER 4. 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. 5. If you have a claim against the above mentioned decedent, estate or trust, please forward documentation to the address indicated in item 4 above. Date:_____________________ ____________________________________________ (Signature of party providing notice) Page 2 of 3 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR023 Rev. 1/1/15 NOTICE TO VICTIM COMPENSATION & GOVERNMENT CLAIMS BOARD Probate Code § 9202(B) Probate Code § 9202 (b) 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 VICTIM COMPENSATION AND GOVERNMENT CLAIMS BOARD, by enclosing a copy in an envelope addressed to: Victim Compensation and Government Claims Board Revenue Recovery and Accounting Division P.O. Box 1348 Sacramento, California 95812-1348 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 PR023 Rev. 1/1/15 NOTICE TO VICTIM COMPENSATION & GOVERNMENT CLAIMS BOARD Probate Code § 9202(B) Probate Code § 9202 (b) American LegalNet, Inc. www.FormsWorkFlow.com