PROBATE COURT OF SUMMIT 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. ________________________________ 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 _________________________________ Typed or Printed Name ________________________________ Address ________________________________ City, State, Zip ________________________________ Telephone Number (include area code) Form 7.0 American LegalNet, Inc. www.USCourtForms.com