PROBATE COURT OF WARREN COUNTY, OHIO ESTATE OF ________________________________________________, DECEASED Case No. ______________________ NOTCE OF 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 filled 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 _______________________________________ Phone Number (include area code) American LegalNet, Inc. www.USCourtForms.com FORM 7.0 – NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM