STATE OF MINNESOTA

COUNTY OF RAMSEY	
SECOND JUDICIAL DISTRICT
DISTRICT COURT
PROBATE DIVISION	

Estate of 

  ___________________________________________, 
Decedent
	
Court File No. _____________________

NOTICE TO COMMISSIONER OF HUMAN SERVICES REGARDING POSSIBLE CLAIMS UNDER MINN. STAT. §§ 246.53, 256B.15, 256D.16 OR 261.04

TO THE COMMISSIONER OF HUMAN SERVICES: 

1.	Attached and served upon you pursuant to Minn. Stat. § 524.3-801, is a copy of the __________________________________________________________ (title of document) and Notice to Creditors which has been or will be published according to law in the above referenced matter. 

(Instructions: Include all aliases and former names of the decedent and spouse(s) in paragraphs 2 and 3 and attach a copy of the Notice to Creditors).
 
2.	Decedent’s Name	Date of Birth	Social Security Number	
	
_____________________________________	
___________________	
______________________                    	

3.  Decedent was married to the following spouse(s) who predeceased decedent: 
	Spouse(s)’s Name	Date of Birth	Social Security Number	
				
	______________________________________	__________________	_____________________	

4.  This Notice is given pursuant to Minn. Stat. § 524.3-801 in case the decedent or a predeceased spouse of decedent might have received assistance for which a claim could be filed under one or more of the following Minnesota Statutes: § 246.53, 256B.15, 256D.16 or 261.04.

NOTE:  Redact the Social Security numbers if filing this form with the County Recorder or Registrar of Titles.

Dated: __________________________________
	______________________________________
Personal Representative	
Attorney for Personal Representative:
Name:  _______________________________
Firm Name:  ___________________________
Address:  _____________________________
_____________________________________
_____________________________________

Attorney License No.:  __________________ 
Telephone:  ___________________________
Fax:  _________________________________
Email:  _______________________________