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.
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Tags: Affidavit Of Notice To TennCare, 165, Tennessee Local County, Hamilton
IN THE CHANCERY COURT
OF HAMILTON COUNTY,
TENNESSEE
AFFIDAVIT OF
NOTICE TO TENNCARE
PART 2
PROBATE DIVISION
FILE N0.
IN THE MATTER OF THE ESTATE OF
DECEASED
STATE OF TENNESSEE
HAMILTON COUNTY
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PURSUANT TO T.C.A. §§ 30-2-301(b)(5), 71-5-116(d)(1)(B),
Affiant, being duly sworn, deposes as follows.
1.
I am the duly qualified personal representative of the captioned estate.
2.
I have personal knowledge of the matters herein stated.
3.
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).
_____________________________________
Affiant
Sworn to and subscribed before me this ____ day of ______________, 20___.
_____________________________________
Notary Public
My Commission Expires: ____________________.
- 1 of 1 Form 165, Rev. 2008.09.18
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