Lorain County Probate Court Judge OF LORAIN COUNTY, PROBATE COURT James T. Walther OHIO 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 the __________ day of ______________, 20______. ____________________________________ Person Responsible for the Estate Mail to: Medicaid Estate Recovery Program 150 E. Gay Street, 21st Floor Columbus, Ohio 43215 ____________________________________ Typed or Printed Name ____________________________________ Address ____________________________________ City, State, Zip ____________________________________ Phone Number (include area code) FORM 7.0 – NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM American LegalNet, Inc. www.FormsWorkFlow.com