1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 CERT _____________________________ Name _____________________________ Address _____________________________ City, State, Zip Code _____________________________ Telephone number/ E-Mail Address IN PROPER PERSON DISTRICT COURT CLARK COUNTY, NEVADA In the Matter of the Estate of: ) ) ) Case No. P__________ ) ) Dept. No. PC-1 ) Deceased. ) CERTIFICATE OF MAILING I HEREBY CERTIFY that service of the Notice of Hearing re: Petition to Set Aside the Estate Without Administration was made 16 this ____ day of ___________________ (month), 20_____ (year), by 17 18 19 20 21 22 23 depositing a copy of the same in the U.S. Mail, postage prepaid, regular mail, addressed to: Welfare and all beneficiaries and heirs) (you are required by statute to mail to Nevada State 1. State of Nevada Dept. of Health and Human Services, Medicaid Estate Recovery, 1000 East Williams Street, #102, Carson City, NV 89701 ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 2. 24 3. 25 26 27 28 4. 5. 6. Page 1 of 2 T:PACKETS\FORM � Certificate of Mailing.Intestate.doc American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7. 8. 9. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 10. ___________________________________________________________ 11. ___________________________________________________________ 7 8 9 10 11 12 12. ___________________________________________________________ DATED this ____ day of ___________, 20_____. Respectfully submitted, By: ________________________ (signature) 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ________________________ (print name) IN PROPER PERSON Page 2 of 2 T:PACKETS\FORM � Certificate of Mailing.Intestate.doc American LegalNet, Inc. www.FormsWorkFlow.com