Clearance Certificate For Public Or Medical Assistance Claim Transfer On Death Deed
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Clearance Certificate For Public Or Medical Assistance Claim Transfer On Death Deed Form. This is a Minnesota form and can be use in Department Of Commerce Statewide.
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Tags: Clearance Certificate For Public Or Medical Assistance Claim Transfer On Death Deed, 10.8.9, Minnesota Statewide, Department Of Commerce
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CLEARANCE CERTIFICATE FOR
PUBLIC/MEDICAL ASSISTANCE CLAIM
Transfer on Death Deed
Minn. Stat. 507.071, subd. 23
Minnesota Uniform Conveyancing Blanks
Form 10.8.9 (2011)
DATE:
(month/day/year)
1. The undersigned is authorized by Minn. Stat. 507.071, subd. 23, and other applicable law, to provide this Clearance Certificate on
County, Minnesota
behalf of the county agency (as defined in Minn. Stat. 507.071, subd. 1) of
(“County Agency”).
2. The real property covered by this Clearance Certificate is located in
and is legally described as follows:
County, Minnesota,
Check here if all or part of the described real property is Registered (Torrens)
3. There
is
is not a claim or lien that is authorized by the statutes listed in Minn. Stat. 507.071, subd. 3, in favor of the
(check only one box)
State of Minnesota or the County Agency against the following decedent:
Decedent’s Full Name
Date of Birth
Date of Death
Amount of Claim
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Minnesota Uniform Conveyancing Blanks Form 10.8.9
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4. There
is
is not a claim or lien that is authorized by the statutes listed in Minn. Stat. 507.071, subd. 3, in favor of the
(check only one box)
State of Minnesota or the County Agency against the following predeceased spouse(s) of the decedent:
Predeceased Spouse(s) Name(s)
Date of Birth
Date of Death
Amount of Claim
5. This Clearance Certificate (check only one box)
is not subject to any conditions or restrictions, or
is subject to the conditions or restrictions attached hereto.
6. If a claim or lien is noted in paragraphs 3 or 4, contact the following person at the County Agency to arrange for payment and
satisfaction of the claim or lien:
Name of contact person:
Telephone number/ email address:
County Agency
By:
(signature of authorized signer)
(name of County Agency)
State of Minnesota, County of
This instrument was acknowledged before me on
, by
(month/day/year)
, as authorized signer for
County, Minnesota.
(Stamp)
(signature of notarial officer)
Title (and Rank):
My commission expires:
(month/day/year)
THIS INSTRUMENT WAS DRAFTED BY:
(insert name and address)
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