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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13033 07/08 STATE OF WISCONSIN Wisconsin Statutes Section 859. 07 PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859. DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13033 07/08 STATE OF WISCONSIN Wisconsin Statutes Section 859. 07 PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859. 07 2 867. 01 3 d and 867. 02 2 d. Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. Failure to complete this form is covered under Wisconsin Statutes ss. 859. 02 and 865. 17. In the Matter of the Estate of Name of Deceased County Social Security Number Type of Probate Date of Death File Number Date of Birth Final Date to File Claims Check here if the Deceased received any of the following Medicaid benefits under s. 49. 46 or 49. 47 Wis. Stats. Medicaid Community Waiver Program s benefits under s. 46. 27 through 46. 278 Wis. Stats. Medicaid or Non-Medicaid Family Care benefits under s. 46. 286 Wis. Stats. Medicaid Purchase Plan MAPP benefits under s. 49. 472 Wis. Stats. Wisconsin Community Options Program COP benefits under s. 46. 27 Wis. Stats. Wisconsin Chronic Disease Program WCDP benefits under s. 49. 68 through 49. 685 Wis. Stats. Check here if a predeceased spouse of the Deceased received any of the following and include his/her name and Name of predeceased Spouse SSN of predeceased Spouse Disclosure of Social Security Number of a Medicaid recipient is mandatory per 42 U*S*C. 1320b-7 identification of COP and WCDP recipients and for the administration of the Estate Recovery Program Name of Personal Representative/Petitioner Mailing Address Name of Attorney PROOF OF MAILING I being duly sworn on oath certify that on the day of mailed via the U*S* Postal Service by registered or certified mail a true and correct copy of this Notice to the State of Wisconsin and to the County Clerk of the decedent s county of residence and I have filed the original Notice with the Register in Probate for the county listed above as required by ss. 859. 07 867. 01 and 867. 02 Wis. Stats. They have been mailed as follows Original to Register in Probate of county listed above Copy to Department of Health Services Estate Recovery Program Section P. O. Box 309 Madison WI 53701-0309 COUNTY CLERK of the decedent s county of residence Subscribed and sworn to before me on Signature Notary Public/Court Official My commission expires Reset Form. 07 PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859. 07 2 867. 01 3 d and 867. 02 2 d. Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. 07 2 867. 01 3 d and 867. 02 2 d. Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. Failure to complete this form is covered under Wisconsin Statutes ss. 859. 02 and 865. 17. In the Matter of the Estate of Name of Deceased County Social Security Number Type of Probate Date of Death File Number Date of Birth Final Date to File Claims Check here if the Deceased received any of the following Medicaid benefits under s.