Nebraska State Court Form REQUIRED NOTICE � NO NOTICE TO DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIRED CC 15:5.1 New 02/2016 Neb. Rev. Stat. �77-2018.02(6) IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA In the Matter of the Estate of: _________________________________ (Decedent) Case #____________________ NOTICE � NO NOTICE TO DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIRED Pursuant to Neb. Rev. Stat. �77-2018.02(6), notice is not required to the Nebraska Department of Health and Human Services as the decedent was NOT 55 years of age or older and/or did NOT reside in a medical institution as defined in Neb. Rev. Stat. �68-919(1) at the time of their death. Therefore the petitioner is not required to notify the Nebraska Department of Health and Human Services that a petition for the determination of inheritance tax was filed with this court and is not required to provide a Certificate of Mailing of such. _______________________________________ Signature of Petitioner(s) ______________________________________ Print or Type Name _______________________________________ Bar Number and Firm Name (attorneys only) _______________________________________ Phone Date______________________________________ __________________________________________ Street Address/P.O. Box __________________________________________ City/State/ZIP Code of __________________________________________ E-mail Address Page 1 of 1 Notice � No Notice to Department of Health and Human Services Required CC 15:5.1 New 02/16 American LegalNet, Inc. www.FormsWorkFlow.com