PC-E-7.0 (Rev. 9-2014) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE ESTATE OF CASE NO. , DECEASED CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM [R.C. 2117.061 and 5162.21] THIS FORM SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF NOTICE TO ADMINISTRATOR The undersigned certifies that s Notice in compliance with Ohio Revised Code 2117.061 and 5162.21 was served upon the following by a method authorized by Civ.R 73 on the day of , 20 . Medicaid Estate Recovery 150 E. Gay Street, 21st Floor Columbus, Ohio 43215 Attorney for Applicant Typed or Printed Name Address City, State, Zip Code Telephone Number (include area code) Attorney's Registration No. Person Responsible for the Estate Signature Typed or Printed Name Address City, State, Zip Code Telephone Number (include area code) FORM E-7.0 - CERTIFICATION NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM American LegalNet, Inc. www.FormsWorkFlow.com