PROBATE COURT OF SHELBY COUNTY, 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. ___________________________________ Attorney ____________________________________ □ Executor _______________________________ Address ________________________________ □ Administrator _______________________________ City, State, Zip ________________________________ □ Commissioner _______________________________ Telephone Number ________________________________ □ 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, 150 E. Gay St., 21st Floor, Columbus, OH 43215, on this _____________ day of __________________________, 20_____. ________________________________ Person Responsible for the Estate ________________________________ Typed or Printed Name ________________________________ Address ________________________________ City, State, Zip ________________________________ Telephone Number (include area code) Form 7.0 – NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM 03/23/04 American LegalNet, Inc. www.FormsWorkflow.com