Affidavit Of Notice To TennCare
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Affidavit Of Notice To TennCare Form. This is a Tennessee form and can be use in Hamilton Local County.
Tags: Affidavit Of Notice To TennCare, 165, Tennessee Local County, Hamilton
IN THE CHANCERY COURT
OF HAMILTON COUNTY,
NOTICE TO TENNCARE
IN THE MATTER OF THE ESTATE OF
STATE OF TENNESSEE
PURSUANT TO T.C.A. §§ 30-2-301(b)(5), 71-5-116(d)(1)(B),
Affiant, being duly sworn, deposes as follows.
I am the duly qualified personal representative of the captioned estate.
I have personal knowledge of the matters herein stated.
As the decedent was 55 years or older at time of death, I verily affirm that on the ___________
day of _________________, 20___, I provided to the Bureau of TennCare the TENNCARE
ELIGIBILITY VERIFICATION/REQUEST FOR RELEASE OF ESTATE RECOVERY COST CLAIM (TC-0087),
as required by T.C.A. § 71-5-116(d)(1)(B).
Sworn to and subscribed before me this ____ day of ______________, 20___.
My Commission Expires: ____________________.
- 1 of 1 Form 165, Rev. 2008.09.18
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