PROBATE COURT OF STARK COUNTY, OHIO , DECEASED ESTATE OF CASE NO. NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM [R.C. 21 17.061] The undersigned gives notice to the Administrator of the Estate Recovery Program that the decedent was fifty-five (55) years of age or older a t the time of death and has been determined to have been a recipient of medical assistance under Chapter 51 11 of the Revised Code. 0 Executor 0 Administrator 0 Commissioner 0 Person who filed pursuant to 21 13.03 of the Revised Code for release of administration. CERTIFICATE OF SERVICE This is t o certify a true copy of the above notice w a s served by certified U.S. mail, postage prepaid to the Administrator of the Estate Recovery Program on the day of ,200__ . Person Responsible for t h e Estate Typed or Printed Name Address City, State, Zip Phone Number (include area code) American LegalNet, Inc. www.USCourtForms.com FORM 7.0 - NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM 4/8/04