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.,� "" "A— ui..16. 440-237-6030 <br /> Ohio Depastued of Joh sae Family Seviess <br /> NOTICE TO MEDICAID ESTATE RECOVERY OF PENDLNC TRANSFER OP PROPER <br /> BY TRANSFER ON DEATH DE D <br /> S Malice is to be completed by the decedent's beneficiary, or authorised representative of the benefcid <br /> vided to the Count'Recorder along with the affidavit and certified copy of the death certificate cate re <br /> er the Ohio Revised Code for uanvisr of the deceased owner's interest, Prior to recording the trwsli <br /> tasty Recorder shall attach a cop,of the deed and mail it with a copy e f the signed notice th: <br /> Administrator,Medicaid Estate Recovery Program <br /> do:Attorney General,Collections Enforcement <br /> 150 East Gay Street,21ie Floor <br /> Columbus,Ohio 43215 <br /> Administrator of the Medicaid Estate Recovery Program will respond to a properly completed=do <br /> v (30) days of receipt erf the notice to either release or encumber the property under the Medicate <br /> ate <br /> very Program Incomplete or incorrect notices will delay this procesa <br /> ION 1-DECEASED PROPERTY OWNER NAME AND PROPERTY ADDRESS 6C5eEr6 <br /> teDeoedeat C U 5 Pt 7f--112:1 LL A --- <br /> east ---- <br /> 316 3 S 1.-Oeft113 tad. <br /> �t TIA 0LH STUD <br /> State <br /> CM-I0'a68wvlotrow! (� �iD� 1G�b�dl�e� <br /> ON 2-INFORMATION REGARDING TEE DECEASED'PROPERTY OWNER <br /> he deceased property owner was not a Medicaid recipient <br /> deceased property owner may have been a Medicaid recipient ' Social Scow "�'ber <br /> is deceased property owner was a Medicaid recipient ' 12-digit Medicaid billing ma <br /> reeks reekpieoi was the deceased proptty ewer aged 55 or oldies(the time thsy,=eceivsd I fiyi7 <br /> s 01111 No <br /> )N 3-INFORMATION REGARDING TUB DECEASED PROP RT'Y OWNER'S ME-DECEASED SI <br /> :e deceased owner's pre-deceased spouse Was-not a Medicaid ipiant. <br /> Social <br /> e deceased owner's pre-deceased spouse may-have,sheen a 3uiec�icaid r pient s umber <br /> e deceased owner's pre-deceased spouse wa 'a.Medicaid.recipient� tz�gict eetat, ingauan <br /> anal recigerisA was the deceased peeps*owner's p eoased apcuu s4pda or adored the time they receivedMedicaid benefits? <br /> 9 DO No <br /> N 4-INFORMATION REGARDING-$ENEIIICIAAY' <br /> etieiay a chi1Q under the e;e tuft**,ens(21)or a Paty deeebled child of the decedent? . <br /> kg No <br />