PC-E-7.0 (Rev. 5-2004) PROBATE COURT OF FRANKLIN COUNTY, OHIO LAWRENCE A. BELSKIS, JUDGE JUDGE ERIC BROWN ESTATE OF , DECEASED CASE NO. 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. 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 . Signature of Person Responsible for the Estate Address: Typed or Printed Name Medicaid Estate Recovery Unit 150 E. Gay Street, 21st Floor Columbus, Ohio 43215-3130 Address City, State, Zip Telephone Number [include area code] FORM 7.0 - NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM American LegalNet, Inc. www.FormsWorkflow.com