(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 (2014) 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 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 predeceased spouse(s) in paragraphs 2 and 3 and attach copy of Notice to Creditors.) (insert title of document) 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: Predeceased 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