San Luis Obispo — PR022

Source: https://www.slo.courts.ca.gov/documents/san-luis-obispo/PR_022_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 DEPARTMENT OF HEALTH CARE SERVICES Probate Code §§ 215, 9202 (a), 19202

1. You are hereby given notice of administration of the estate 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. The decedent received or may have received health care under Chapter 7 (commencing with Section

14000. or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or had a predeceased spouse or registered domestic partner who received or may have received health care.

4. The decedent:

   a. Did not have a predeceased spouse or registered domestic partner (or)

   b. Did have a predeceased spouse or registered domestic partner, a copy of whose death certificate is attached.

Form Adopted for Optional Use NOTICE TO DEPT OF HEALTH CARE SERVICES Probate Code §§ 215. 9202(a) and 19202San Luis Obispo Superior Court Local Form PR022 Probate Code §§ 215. 9202(a) and 19202 Rev. 1/1/15

Insert case name: CASE NUMBER

5. 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.

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

Date:_____________________ ____________________________________________
(Signature of party providing notice)

Form Adopted for Optional Use NOTICE TO DEPT OF HEALTH CARE SERVICES Probate Code §§ 215. 9202(a) and 19202San Luis Obispo Superior Court Local Form PR022 Probate Code §§ 215. 9202(a) and 19202 Rev. 1/1/15

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 DEPARTMENT OF HEALTH CARE SERVICES, by enclosing
a copy in an envelope addressed to:

Department of Health Care Services
Estate Recovery Unit
P.O. Box 997425, MS 4720
Sacramento, California 95899-7425

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 DEPT OF HEALTH CARE SERVICES Probate Code §§ 215. 9202(a) and 19202San Luis Obispo Superior Court Local Form PR022 Probate Code §§ 215. 9202(a) and 19202 Rev. 1/1/15