In the District Court of Iowa in and for County
In the Estate of , Deceased. Probate No.

To the Iowa Department of Health and Human Services, Who May Be Interested in the Estate of the above deceased person, who died on or about (date):

You are hereby notified that on (date), the last will and testament for the above deceased person, bearing date of (date), was admitted to probate in the above-named court and that was appointed executor of the estate. The birth date of the deceased is (date) and the deceased's social security number is - - .

You are further notified that:
() The deceased was never married.
() The deceased was divorced and unremarried at the time of death.
() The deceased was preceded in death by a spouse who died prior to July 1, 1994.
() The deceased has a surviving spouse with the name , birth date , and social security number - - .
() The deceased was preceded in death by a spouse with the name , birth date , and social security number - - , and date of death (on or after July 1, 1994).
() The deceased received a waiver for a disability or undue hardship from the department with regard to another person s medical assistance debt whose name was and social security number was - - .

Notice is hereby given that if the Iowa Department of Health and Human Services has a claim against the estate for the deceased person or persons named in this notice, the claim shall be filed with the clerk of the above-named district court, as provided by law, duly authenticated, for allowance, within six months of the date of sending this notice or the claim is thereafter forever barred. If the Department does not have a claim, the Department shall return a notice to the Executor within six months of the date of this notice that the Department does not have a claim. No further notice from the Executor by mail or otherwise is required, so none will be provided.

Attorney for Executor Date
Address
City, State, Zip
Phone #
Attorney Fax Email Address
Further comments:

470-4494 (7/10)