Fill and Sign the Affidavit of Nursing Home Administrator New Hampshire Form

NHJB-2147-P (06/07/2012) Page 1 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF NURSING HOME ADM INISTRATOR (RSA 151-A:15) I, the nursing home administr ator, state the following: 1. Administrator’s Name Telephone Number Nurs in g H om e N am e Nurs in g H om e A ddre ss 2. was a resident at th e above-named nursing home. His/her Medicaid number was 3. The above-named resident was admitted to this nursing home on and died on 4. Following are the contacts of the deceased resident; I am not aware of any other contacts. Name and Address Telephone Number Relationship 5. Nursing home records: do not indicate that a will exists. include a will or copy of a will which is attac hed to this affidavit. indicate that a will is held by who is listed in #4 above as a contact. 6. No one has filed for administration under RSA 553 in the county where the deceased last resided. 7. The gross value of the deceased’s personal property remaining at the nursing home is $ (This amount may not exce ed $5,000.) 8. The deceased’s known debts or obligations are as listed below. (Attach additional sheets if necessary.) Expenses of Estate Administration $ Necessary Charges for Funeral & Burial $ Federa l T axe s $ Claims by DHHS including Medi caid liability $ Debts and other General Creditors $ Case Name: Case Number: AFFIDAVIT OF NURSING HOME ADMINISTRATOR (RSA 151-A:15) NHJB-2147-P (06/07/2012) Page 2 of 2 9. I certify, in accordance with Pr obate Court Rule 21, that I have sent copies of this affidavit by first class mail to the following: (a) All known contacts as listed in #4 above; (b) Office of Estate Re coveries, Department of Health and Human Serv ices, 129 Pleasant St., Concord, NH 03301; and (c) Department of Revenue Ad ministration, Post Office Box 457, Concord, NH 03302-0457 (if death was prior to January 1, 2003). 10. I request authorization by the Court to pay all known debts of the deceased in accordance with statutory priorities, and to pay an y remaining funds of the decedent to the State Treasurer to be held as abandoned property pursuant to RSA 471-C. Date Nursing Home Administrator Signature State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER Authorization is granted for the Nursing Home Administrator to pay all known debts of the decedent, as enumerated in #8 above or on the attached sheet(s), in accordance with statutory priorities, and to pay any remaining funds of t he decedent to the State Treasurer to be held as abandoned property pursuant to RSA 471-C. Authorization is denied for the following reasons: Date Signature of Judge Printed Name of Judge