Riverside — Notice to Department of Health Care Services (RI-PR036)

Source: https://www.riverside.courts.ca.gov/system/files/ri-pr036.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE

MURRIETA 30755-D Auld Rd., Murrieta, CA 92563 RIVERSIDE 4050 Main St., Riverside, CA 92501

PALM SPRINGS 3255 E. Tahquitz Canyon Wy., Palm Springs, CA 92262 RI-PR036

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

IN THE MATTER OF:

CASE NUMBER:

NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code §§ 215, 9202(a),19202

You may instead submit this notice online at: dhcs.ca.gov/services/Pages/EROnlineForms.aspx

1. You are hereby given notice of the death of the following person: a. Decedent’s Name:

   b. Date of Birth:

   c. Date of Death:

   d. 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. a. The decedent did not have a predeceased spouse or registered domestic partner. (or)

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

5. Total estimated value of assets: .

6. (Check any of the following that apply): a. Decedent’s spouse or registered domestic partner is still living.

   b. Decedent is survived by a child under the age of 21, as of the date of death.

   c. Decedent is survived by a child of any age, who is blind or disabled.

   d. Decedent owns property that is on or near a federally-recognized Reservation, Pueblo, or Colony.

Approved for Optional Riverside Superior Court Use NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code §§riverside.courts.ca.gov215, 9202(a),19202 RI-PR036 [Rev. 01/14/26] Probate Code §§ 215, 9202(a), 19202

IN THE MATTER OF: CASE NUMBER:

5. The party providing you with this notice is as follows: a. Name:

   b. Address:

   c. Telephone:

   d. Capacity: Estate Attorney, Beneficiary/Heir, Personal Representative, Person in Possession of Property of the Decedent, Trustee Conservator Guardian

6. This notice is being provided by a general personal representative, trustee, or the attorney who represents a general personal representative or trustee. If you have a claim against the above-mentioned estate or trust please forward documentation to the address indicated in item 5 above within the period provided in Probate Code 9202(a) or 19202(b).

Date: (PARTY PROVIDING NOTICE)

PROOF OF SERVICE BY MAIL

1. I am over the age of 18 and am not a party in this cause. I am a resident of or employed in the county where the mailing occurred.

2. My (the servers) home or business address is : (STREET ADDRESS) (CITY, STATE, ZIP)

3. I served the forgoing NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES by enclosing a copy in an envelope addressed

   as shown below and depositing the sealed envelope on the date and at the place shown in item 4 with the United States Postal Service with the postage fully prepaid.

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

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

5. I served with the notice a copy of the Letters of Administration filed on (date): and/or the
   Inventory and Appraisal documents filed on (date(s)): .

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

Date:

(TYPE OR PRINT NAME) (SIGNATURE)

Approved for Optional Riverside Superior Court Use NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES Probate Code §§riverside.courts.ca.gov215, 9202(a),19202 RI-PR036 [Rev. 01/14/26] Probate Code §§ 215, 9202(a), 19202