JFS 07408 (Rev. 8/2008) Page 2 of 2
SECTION 4 - INFORMATION REGARDING BENEFICIARY
If the beneficiary is a son or daughter of the Decedent: (1) Is the beneficiary a child under the age of twenty-one (21) Yes No ;
(2) Is the beneficiary age twenty-one (21) and over, AND “blind” or “disabled” under the definition contained in 42 USC 1382c? Yes No
SECTION 5 - CERTIFICATION OF BENEFICIARY OR BENEFICIARY'S REPRESENTATIVE
By my status selection and signature below, I certify that I am the beneficiary, or the beneficiary's authorized
representative, of the property listed in Section 1 of this notice, and as described in the attached transfer-on-death
deed. I further certify that the information provided in this notice is complete and accurate to the best of the
beneficiary's, and beneficiary's authorized representative's knowledge. (NOTE: For beneficiaries who have
authorized representatives, only the name of the beneficiary is required in the left column, as all of the authorized
representative’s details will be provided in the right hand column).
Name
Information about Beneficiary
Information about Beneficiary’s Authorized Representative
Address
City, State Zip
Home/Work Phone
Cell/Fax (specify)
Status Selection (check one)
Beneficiary Authorized Representative of the Beneficiary
Signature of Beneficiary OR Beneficiary’s Authorized Representative Date Signed
* Social Security Numbers:
• Are only required to be provided when the decedent or the decedent’s pre-
deceased spouse is believed to have received Medicaid.
• Are required for purposes of identifying former recipients of Medicaid, and to
determine if any estate recovery is warranted. The Ohio Department of Job and
Family Services is authorized to collect the social security numbers of Medicaid
applicants and recipients, and to pursue recovery of any sums owed to Ohio
Medicaid, pursuant to 42 CFR 431.302, 42 CFR 431.305; Ohio Revised Code
(ORC) Sections 5101.181, 5101.182 and 5111.01; and, Ohio Administrative Code
(OAC) Rule 5101:1-38-02.1.
• Will be treated as confidential, and will only be used for purposes directly
connected with the administration of the Medicaid program, which includes
overpayment recovery and collection.
• Must be provided for any decedent or decedent’s spouse believed to have received
Medicaid; and, if not provided, could result in incorrect matches, as well as the
potential for setting aside of the real estate transfer, upon subsequent discovery of
the Medicaid recipient’s ownership interest in the estate.
