AFFIDAVIT TO TRANSFER PROPERTY TO TRANSFER ON DEATH BENEFICIARY (ORC 5302.22) STATE OF OHIO, COUNTY OF __________________. The undersigned, being first duly cautioned and sworn, state that he/she has personal knowledge of the following information. 1.) The record owner of the real property described on attached EXHIBIT “A” is ________________________________, who died on _____________________, (Deceased owner) (Date of death) a certified copy of the death certificate is attached hereto as EXHIBIT “B”. 2.) The Transfer on Death Deed is dated ______________________ and recorded at _________________________, in the Recording Office in______________ (Recording number/book & page) County, Ohio 3.) The following person(s),designated as Transfer on Death Beneficiary(s) pursuant to the Transfer on Death Deed, referred to above, survived or are in existence on the date of the property owner’s death: NAME ADDRESS ___________________________ _____________________________ ___________________________ _____________________________ ____________________________ ______________________________ FOR DEATH OF BENEFICIARY(S) ONLY 4.) The following person(s), designated as Transfer on Death Deed Beneficiary(s) pursuant to the Transfer on Death Deed did not survive or are not in existence on the date of the property owner’s death: NAME ADDRESS ____________________________ ______________________________ _____________________________ _______________________________ ______________________________ ________________________________ and (a) certified copy(s) of their death certificate(s) is/are attached as EXHIBIT “C”. FOR CONTINGENT BENEFICIARY(S) ONLY American LegalNet, Inc. www.FormsWorkflow.com 5.) That by virtue of the death of the party(s) listed in item #4, the following person(s), designated as Contingent Transfer on Death Beneficiaries, survived or are in existence on the date of the property owner’s death: NAME ADDRESS ____________________________ ________________________________ ____________________________ _________________________________ _____________________________ __________________________________ All records should reflect that the property described in Exhibit”A” is hereby transferred from the deceased owner to the Transfer on Death Beneficiary(s) or Contingent Transfer on Death Beneficiary(s) ____________________________________ Signature of Affiant Printed name of Affiant COUNTY OF _____________________ STATE OF OHIO Sworn to before me and subscribed in my presence this ________ day of ________________, 20____. ____________________________________ Notary Public ____________________________________ Print Name and expiration date This instrument prepared by: _______________________ American LegalNet, Inc. www.FormsWorkflow.com JOHN A. DONOFRIO Fiscal Officer County of Summit To: All Title Companies, Title Examiners, and Attorneys From: John A. Donofrio Summit County Fiscal Officer Re: Medicaid Estate Recovery Date: February 2008 Under federal law all states are required to recover taxpayers' funds, spent on certain Medicaid services, from the estates of those persons who received the services. In Ohio, the program is administered jointly by the Ohio Department of Job and Family Services (ODJFS) and the Ohio Attorney General's Office (AGO). http://jfs.ohio.gov/ Estate recovery seeks to obtain repayment of the cost of Medicaid benefits once a Medicaid recipient is deceased. This happens after the death of a Medicaid recipient who was either permanently institutionalized of age 55 or older. Information is also available online at http://ag.state.oh.us/business/estate_recovery.asp Attached is the state mandated form ORC 5302.221 that must accompany all affidavits for Transfer on Death. This form is required by law to be presented to the Fiscal Office Recording Division each time an affidavit for a Transfer on Death deed is recorded. If you have questions or need further information, contact Dyann James, Director of Administration of the Recording Division at 330-643-2715. AUDITOR DIVISION 175 S. Main Street Akron, OH 44308 Phone: 330.643.2625 Fax: 330.643.2622 RECORDING DIVISION 175 S. Main Street Akron, OH 44308 Phone: 330.643.2719 SERVICE DIVISION 1030 E. Tallmadge Ave Akron, OH 44310 Phone: 330.630.7226 Fax: 330.630.7240 TREASURER DIVISION 175 S. Main Street Akron, OH 44308 Phone: 330.643.2606 Fax: 330.643.7760 American LegalNet, Inc. www.FormsWorkflow.com Ohio Department of Job and Family Services NOTICE TO MEDICAID ESTATE RECOVERY OF PENDING TRANSFER OF PROPERTY BY TRANSFER ON DEATH DEED This notice is to be completed by the decedent's beneficiary, or authorized representative of the beneficiary, and provided to the County Recorder along with the affidavit and certified copy of the death certificate required under the Ohio Revised Code for transfer of the deceased owner's interest. Prior to recording the transfer, the County Recorder shall attach a copy of the deed and mail it with a copy of the signed notice to : Administrator, Medicaid Estate Recovery Program c/o: Attorney General, Collections Enforcement 150 East Gay Street, 21st Floor Columbus, Ohio 43215 The Administrator of the Medicaid Estate Recovery Program will respond to a properly completed notice within thirty (30) days of receipt of the notice to either release or encumber the property under the Medicaid Estate Recovery Program. Incomplete or incorrect notices will delay this process. SECTION 1 - DECEASED PROPERTY OWNER NAME AND PROPERTY ADDRESS Name of Decedent Property Address of Decedent City State (2-letter abbreviation) Zip Code SECTION 2 - INFORMATION REGARDING THE DECEASED PROPERTY OWNER The deceased property owner was not a Medicaid recipient. The deceased property owner may have been a Medicaid recipient The deceased property owner was a Medicaid recipient Social Security number 12-digit Medicaid billing number If a Medicaid recipient, was the deceased property owner aged 55 or older at the time they received Medicaid benefits? Yes No SECTION 3 - INFORMATION REGARDING THE DECEASED PROPERTY OWNER'S PRE-DECEASED SPOUSE The deceased owner's pre-deceased spouse was not a Medicaid recipient. The deceased owner's pre-deceased spouse may have been a Medicaid recipient The deceased owner's pre-deceased spouse was a Medicaid recipient Social Security number 12-digit Medicaid billing number If a Medicaid recipient, was the deceased property owner's pre-deceased spouse aged 55 or older at the time they received Medicaid benefits? Yes No SECTION 4 - INFORMATION REGARDING BENEFICIARY Is the beneficiary a child under the age of twenty-one (21) or a permanently disabled child of the decedent? Yes JFS 07408 (12/2007) No Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com SECTION 5 - CERTIFICATION OF BENEFICIARY OR BENEFICIARY'S REPRESENTATIVE By my status selection and signature below, I certify that I am the beneficiary, or the beneficiary's authorized representative, of the property listed in Section 1 of this notice, and as described in the attached transfer-on-death deed. I further certify that the information provided in this notice is complete and accurate to the best of the beneficiary's, and beneficiary's authorized representative's knowledge. Name of Beneficiary or Authorized Beneficiary Representative Address City State (2-letter abbreviation) Telephone Number (including area code) Zip Code Supplemental Contact Information (FAX number, cellular phone, etc. Please specify type) Status Selection (check one) Beneficiary Signature of Beneficiary or Authorized Beneficiary Representative JFS 07408 (12/2007) Authorized Representative of the Beneficiary Date of Signature Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com