PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge ESTATE OF _______________________________________________, DECEASED CASE NUMBER ______________________________________ NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM [R.C. 2117.061] The undersigned gives notice to the Administrator of the Estate Recovery Program that the decedent was fifty-five (55) years of age or older at the time of death and has been determined to have been a recipient of medical assistance under Chapter 5111 of the Revised Code. ______________________________________________ 9 9 9 9 Executor Administrator Commissioner Person who filed pursuant to 2113.03 of the Revised Code for release from administration CERTIFICATE OF SERVICE This is to certify a true copy of the above notice was served by certified U.S. mail, postage prepaid to the Administrator of the Estate Recovery Program, on ______________________ day of _______________________, 20______ . __________________________________ Person Responsible for the Estate __________________________________ Typed or Printed Name __________________________________ Address __________________________________ City, State, Zip Code __________________________________ Phone Number (include Area code) Form 7.0 - notice to administrator of estate recovery program 10/03 American LegalNet, Inc. www.FormsWorkflow.com