PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE 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 ____________________200__. __________________________________________________ Person Responsible for the Estate ______________________________________________ Typed or Printed Name ______________________________________________ City, State, Zip ______________________________________________ Phone Number (include area code) FORM 7.0-NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM 4/8/04 American LegalNet, Inc. www.USCourtForms.com