Statement Of Claim Request Form
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Statement Of Claim Request Form. This is a Pennsylvania form and can be use in Department Of Public Welfare Statewide.
Tags: Statement Of Claim Request Form, Pennsylvania Statewide, Department Of Public Welfare
Statement of Claim Request Form002 DECEDENT222S NAME: DECEDENT222S LAST KNOWN ADDRESS: (Prior to entering nursing home.) (CITY, STATE, ZIP CODE) DECEDENT222S SOCIAL SECURITY NUMBER: / / DECEDENT222S DATE OF BIRTH: DECEDENT222S DATE OF DEATH: GROSS AMOUNT OF DECEDENT222S ESTATE: (Written documentation must be included.) PERSONAL REPRESENTATIVE222S NAME: PERSONAL REPRESENTATIVE222S ADDRESS: (CITY, STATE, ZIP CODE) PERSONAL REPRESENTATIVE222S PHONE NUMBER: ( ) ESTATE ATTORNEY222S NAME: ESTATE ATTORNEY222S ADDRESS: (CITY, STATE, ZIP CODE) ESTATE ATTORNEY222S PHONE NUMBER: ( ) ESTATE ATTORNEY222S FAX NUMBER: ( ) ESTATE ATTORNEY222S EMAIL ADDRESS (OPTIONAL): SEND TO: DEPARTMENT OF HUMAN SERVICES DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM P.O. BOX 8486 HARRISBURG, PA 17105-8486 ESTATE RECOVERY HOTLINE 1-800-528-3708 FAX: (717) 772-6553 HS 1780 4/18 American LegalNet, Inc. www.FormsWorkFlow.com
