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Affidavit Re TennCare Enrollment Form. This is a Tennessee form and can be use in Hamilton Local County.
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Tags: Affidavit Re TennCare Enrollment, 146, Tennessee Local County, Hamilton
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Index No.
Calendar No.
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IN THE CHANCERY COURT FOR HAMILTON COUNTY, TENNESSEE
JUDICIAL SUBPOENA
Plaintiff(s)
*
-against-
IN THE MATTER OF THE ESTATE OF
*
_______________________________, Deceased
:
*
ØØØØØ×××××
:
N0. _____________
PART 2
:
*
PROBATE DIVISION
Defendant(s)
:
. ._______________________________, . . . . . . . . . . . . .*. . . . .
..................................
Personal Representative(s)
*
THE PEOPLE OF THE STATE OF NEW YORK
AFFIDAVIT RE TENNCARE ENROLLMENT
T.C.A. § 71-5-116(c)(2)
TO
State of Tennessee}
County of Hamilton}
GREETINGS:
WE COMMAND YOU, that all business and say(s):
The undersigned, being duly sworn, depose(s) and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
1. The
located at
County of undersigned is/are the duly appointed and serving personal representative(s) of this
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
estate.
or adjourned date, to testify and give evidence as a witness in this action on the part of the
2.
The undersigned has/have personal knowledge of the matters herein stated.
3.
The undersigned verily affirm(s) that the decedent, at time of death, was fifty-five (55) years
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
of on or older. T.C.A. 71-5-116(c).
the party agewhose behalf this§subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply. affirm(s) that the decedent, at time of death, was not enrolled in the
4. The undersigned verily
TennCare Program in Tennessee.
Witness, Honorable
, one of the Justices of the
Court in
(s) saith
5. Further AffiantCounty, not. day of
, 20
___________________________________
(Attorney must sign above and type name below)
____________________________________
Personal Representative
Personal Representative
Sworn to and subscribed before me this _______ day of __________________________, 20 ___.
Attorney(s) for
___________________________________
NOTARY PUBLIC
My commission expires _________________
[Form 146, Rev. 2002.11.04]
Page 1 of 1.
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