San Luis Obispo — PR023

Source: https://www.slo.courts.ca.gov/documents/san-luis-obispo/PR_023_SLO.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY

TELEPHONE NUMBER: FAX NO. (Optional):

EMAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO

STREET ADDRESS: 1035 Palm Street, Room 385 MAILING ADDRESS: Same as above CITY AND ZIP CODE: San Luis Obispo, CA 93408 BRANCH NAME: San Luis Obispo Division

ESTATE OF: CASE NUMBER:

NOTICE TO VICTIM COMPENSATION & GOVERNMENT CLAIMS BOARD Probate Code § 9202 (b)

1. You are hereby given notice of the death of the following person:

   a. Decedent’s Name:_____________________________________________________________.

   b. Date of Death:________________________________________________________________.

   c. Social Security Number:_________________________________________________________.

2. A copy of the decedent’s death certificate is attached.

3. At the time of the decedent’s death or during administration of the decedent’s estate, the following heirs or beneficiaries of the decedent’s estate were incarcerated in a facility identified in Probate Code § 216 or § 9202(b):

Name Location of Date of Birth CDCR or Booking Number Incarceration

Form Adopted for Optional Use NOTICE TO VICTIM COMPENSATION & Probate Code § 9202 (b)San Luis Obispo Superior Court Local Form PR023 GOVERNMENT CLAIMS BOARD Rev. 1/1/15 Probate Code § 9202(B)

Insert case name: CASE NUMBER

4. The party providing you with this notice is as follows:

a. Name:_______________________________________________________________________.

b. Address:_____________________________________________________________________.

c. Telephone:___________________________________________________________________.

d. Capacity: Estate Attorney Personal Representative Beneficiary/ Heir Trustee

Person in Possession of the Property of Decedent.

5. If you have a claim against the above mentioned decedent, estate or trust, please forward
documentation to the address indicated in item 4 above.

Date:_____________________ ____________________________________________
(Signature of party providing notice)

Form Adopted for Optional Use NOTICE TO VICTIM COMPENSATION & Probate Code § 9202 (b)San Luis Obispo Superior Court Local Form PR023 GOVERNMENT CLAIMS BOARD Rev. 1/1/15 Probate Code § 9202(B)

Insert case name: CASE NUMBER

PROOF OF SERVICE

1. I am over the age of 18 and am not a party to this case. I live or work in the county where the
mailing occurred.

2. My (the servers) home or business address is as follows:

3. I served the foregoing NOTICE TO VICTIM COMPENSATION AND GOVERNMENT CLAIMS
BOARD, by enclosing a copy in an envelope addressed to:

Victim Compensation and Government Claims Board
Revenue Recovery and Accounting Division
P.O. Box 1348
Sacramento, California 95812-1348

4. Date mailed: _______________, Place mailed (city, state): ________________________ .

I declare under penalty of perjury under the laws of the State of California that the information
above is true and correct.

_________________ ________________________________ ___________________________
(Date signed) (Type or Print Name) (Signature)

Form Adopted for Optional Use NOTICE TO VICTIM COMPENSATION & GOVERNMENT Probate Code § 9202 (b)San Luis Obispo Superior Court Local Form PR023 CLAIMS BOARD Rev. 1/1/15 Probate Code § 9202(B)