PROBATE COURT OF TRUMBULL COUNTY, OHIO JAMES A. FREDERICKA, JUDGE ESTATE OF:_____________________________________________________, DECEASED CASE NO. _______________________ CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM [R.C. 2117.061 AND 5162.21] THIS FORM SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF NOTICE TO ADMINISTRATOR The undersigned certifies that a Notice in compliance with Ohio Revised Code 2117.061 and 5162.21 was served upon the following by a method authorized by Civ.R. 73 on the __________ day of ______________, 20______: Medicaid Estate Recovery 150 E. Gay Street, 21st Floor Columbus, Ohio 43215 _________________________________ Attorney for Applicant _______________________________ Person Responsible for the Estate _________________________________ Typed or Printed Name _______________________________ Typed or Printed Name _________________________________ Address _______________________________ Address _________________________________ City, State, Zip Code _______________________________ City, State, Zip Code _________________________________ Telephone Number (include area code) Attorney Registration No. _______________________________ Telephone Number (include area code) _______________ FORM 7.0 ­ CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM Amended: June 1, 2014 American LegalNet, Inc. www.FormsWorkFlow.com