THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF NURSING HOME ADMINISTRATOR (RSA 151-A:15) I, the nursing home administrator, state the following: 1. Administrator’s Name Telephone Number Nursing Home Name Nursing Home Address 2. was a resident at the above-named nursing home. His/her Medicaid number was His/her social security number was 3. The above-named resident was admitted to this nursing home on and died on 4. Following are the contacts of the deceased resident; I am not aware of any other contacts. Name and Address Telephone Number Relationship 5. Nursing home records: do not indicate that a will exists. include a will or copy of a will which is attached to this affidavit. indicate that a will is held by above as a contact. who is listed in #4 6. No one has filed for administration under RSA 553 in the county where the deceased last resided. 7. The gross value of the deceased’s personal property remaining at the nursing home is $ (This amount may not exceed $5,000.) 8. The deceased’s known debts or obligations are as listed below. (Attach additional sheets if necessary.) Expenses of Estate Administration $ Necessary Charges for Funeral & Burial $ Federal Taxes $ Claims by DHHS including Medicaid liability $ Debts and other General Creditors $ NHJB-2147-P (06/07/2012) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: AFFIDAVIT OF NURSING HOME ADMINISTRATOR (RSA 151-A:15) 9. I certify, in accordance with Probate Court Rule 21, that I have sent copies of this affidavit by first class mail to the following: (a) All known contacts as listed in #4 above; (b) Office of Estate Recoveries, Department of Health and Human Services, 129 Pleasant St., Concord, NH 03301; and (c) Department of Revenue Administration, Post Office Box 457, Concord, NH 03302-0457 (if death was prior to January 1, 2003). 10. I request authorization by the Court to pay all known debts of the deceased in accordance with statutory priorities, and to pay any remaining funds of the decedent to the State Treasurer to be held as abandoned property pursuant to RSA 471-C. Date Nursing Home Administrator Signature State of , County of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any by Signature of Notarial Officer / Title ORDER Authorization is granted for the Nursing Home Administrator to pay all known debts of the decedent, as enumerated in #8 above or on the attached sheet(s), in accordance with statutory priorities, and to pay any remaining funds of the decedent to the State Treasurer to be held as abandoned property pursuant to RSA 471-C. Authorization is denied for the following reasons: Date NHJB-2147-P (06/07/2012) Judge Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com