PA HS 1780 2002 free printable template

STATEMENT OF CLAIM REQUEST FORM DECEDENT'S NAME: DECEDENT'S LAST KNOWN ADDRESS: (Prior to entering nursing home) (CITY, STATE, ZIP CODE) DECEDENT'S SOCIAL SECURITY NUMBER: / / DECEDENT'S DATE OF BIRTH:

How to fill out pa estate recovery statement

How to fill out a PA estate recovery statement:

1. Gather all necessary information: Before starting to fill out the PA estate recovery statement, gather all the required information such as the deceased person's personal details, including their name, date of birth, and social security number. Also, collect any relevant financial information, including details about their assets and debts.
2. Obtain a copy of the estate recovery statement form: You can obtain the PA estate recovery statement form from the Pennsylvania Department of Human Services website or by contacting the appropriate department.
3. Fill out the personal information section: Start by providing the deceased person's personal information in the designated section of the form. This includes their full name, date of birth, and social security number.
4. Provide details about the deceased person's assets and debts: In the next section, itemize and disclose all the assets and debts of the deceased person. List any real estate properties, bank accounts, investments, vehicles, or any other valuable assets they owned. Additionally, detail any outstanding debts or liabilities they may have had.
5. Include information about estate administration: If someone is currently handling the estate administration process, provide their contact information and any relevant details about their role.
6. Attach supporting documentation: To support the information provided in the estate recovery statement, include relevant documents such as bank statements, property deeds, or any other proof of assets and debts.
7. Review and sign the form: Ensure that all the information provided is accurate and complete. Carefully review the estate recovery statement before signing and dating it.

Who needs a PA estate recovery statement?

1. Executors or administrators of a decedent's estate: If you are responsible for managing the estate of a deceased person in Pennsylvania, you may need to fill out a PA estate recovery statement. This form is typically required as part of the estate administration process.
2. Individuals designated to handle estate recovery matters: In some situations, individuals may be appointed specifically to handle estate recovery matters by the Pennsylvania Department of Human Services. These individuals would likely need to complete the PA estate recovery statement.
3. Individuals with legal authority over the deceased person's estate: Anyone with legal authority over the deceased person's estate, such as beneficiaries or trustees, may also be required to fill out a PA estate recovery statement when necessary.

Please note that it is always advisable to consult with an attorney or legal professional specializing in estate planning and administration to ensure compliance with all relevant laws and regulations.

People Also Ask about pa estate recovery statement of claim request form

What is the Pennsylvania estate recovery Statute?

The Estate Recovery Program allows the Commonwealth to recover Medical Assistance payments made on behalf of an individual who received long-term care Medical Assistance [including nursing facility, Home and Community Based Services (HCBS) and related services] from the time they turned 55 until their passing.

How do I make a claim against an estate in Pennsylvania?

You must file out a form and submit it to the register to make the claim official. If the claim is filed by a creditor with the court, their right to proceed is preserved against what is known as the distributee or who receives assets from the estate only if the real property is considered an estate asset.

What is PA estate recovery statute?

The Estate Recovery Program allows the Commonwealth to recover Medical Assistance payments made on behalf of an individual who received long-term care Medical Assistance [including nursing facility, Home and Community Based Services (HCBS) and related services] from the time they turned 55 until their passing.

How do I avoid Medicaid Estate Recovery in PA?

One of the best ways to avoid estate recovery is where a caregiver resides in the Medicaid recipient's home and provides care or support either 1) for two years while the person received home- and community-based services, or 2) for the two years immediately prior to nursing home placement.

What assets are subject to estate recovery in Pennsylvania?

Pennsylvania's Estate Recovery Program can only reach probate assets; any non-probate assets—retirement accounts, jointly-owned property by the decedent and another, and life insurance policies paid directly to a beneficiary—will transfer outside of the estate recovery process.

What is a notice of claim against estate in Pennsylvania?

In Pennsylvania, a person or entity who is owed money by the decedent prior to their death is considered to be a creditor with a claim against the estate. State law requires the personal representative of the estate to put creditors on notice of the estate administration proceedings.

For pdfFiller’s FAQs

What is pa estate recovery statement?

A PA (Pennsylvania) estate recovery statement refers to a document that outlines the state's right to recover funds for Medicaid benefits paid on behalf of a deceased individual from their estate. When someone receives Medicaid benefits, the state may seek repayment of these benefits from their estate after their death. This statement provides details of the amounts owed by the estate to Medicaid for the benefits received.

Who is required to file pa estate recovery statement?

In Pennsylvania, the estate recovery statement is required to be filed by the executor or administrator of a deceased person's estate.

How to fill out pa estate recovery statement?

To properly fill out the Pennsylvania estate recovery statement, follow these steps: 1. Obtain a copy of the estate recovery statement form. You can request the form from the Pennsylvania Department of Human Services or download it from their website. 2. Gather the necessary information. You will need to provide details about the deceased individual, their assets, and their estate. Collect documents such as bank statements, real estate deeds, and insurance policies. 3. Begin filling out the form. Start by entering the decedent's name, date of birth, Social Security number, and date of death. Fill in the applicable sections regarding the decedent's assets, income, and financial resources. Include specific information about any property, bank accounts, vehicles, or other assets they owned. 4. Provide details about any debts or liabilities. Include information about any outstanding mortgages, loans, or other debts that the decedent had at the time of their death. 5. Indicate if the decedent received any medical assistance benefits during their lifetime. Specify the dates of eligibility and the type of benefits received. 6. If the decedent had a surviving spouse, provide their information and specify if any assets were jointly owned between the decedent and their spouse. 7. Sign and date the form. If you are the personal representative or executor of the estate, you will need to sign the form. If you are not, ensure that the person authorized to sign on behalf of the estate fills in their information. 8. Attach any necessary documentation. Include copies of any supporting documents that verify the information provided on the form, such as death certificates, asset valuations, and property titles. 9. Submit the completed form and attachments. Mail the estate recovery statement to the address specified on the form or as directed by the Pennsylvania Department of Human Services. Keep a copy for your records. 10. Wait for a response. The Pennsylvania Department of Human Services will review the form and documentation and determine if the estate is subject to recovery or if further information is needed. They will communicate their decision to you in writing. It is advisable to seek legal or financial advice if you are unsure about how to accurately complete the estate recovery statement or if you have complex estate matters to address.

What is the purpose of pa estate recovery statement?

The purpose of a PA estate recovery statement is to determine if the Pennsylvania Department of Human Services (DHS) has the right to seek reimbursement from a deceased individual's estate for certain medical assistance benefits received during their lifetime. The estate recovery program allows the state to recover funds paid out for medical assistance services such as nursing home care, home and community-based services, and prescription drugs. The statement helps identify any assets or resources in the deceased individual's estate that may be subject to recovery by the state. This process helps ensure that individuals who received medical assistance benefits from the state repay them if they have the means to do so. It allows the state to recoup some of the costs associated with providing these services and helps sustain the program in the long run.

What information must be reported on pa estate recovery statement?

In Pennsylvania, the following information must be reported on an Estate Recovery Statement: 1. Identification of the decedent: The statement must include the full name, date of birth, and date of death of the deceased individual. 2. Estate Information: The statement should provide a detailed inventory of the assets and liabilities of the estate. This may include real estate, bank accounts, investments, personal property, and any other valuable assets. 3. Probate Information: The statement should list the probate case number, the name of the probate court, and the name of the personal representative or executor administering the estate. 4. Medical Assistance Benefits Received: The statement must include the total amount of Medical Assistance benefits received by the decedent during their lifetime. This may include long-term care expenses, nursing home costs, hospital bills, and any other medical expenses covered by the Medical Assistance program. 5. Recoverable Medical Assistance Costs: The statement should calculate and specify the total amount of recoverable Medical Assistance costs, which is the amount the state is entitled to collect from the estate. This may include both the original amount of benefits paid and any interest or administrative costs incurred. 6. Payment Demand: The statement should indicate the specific amount demanded by the Pennsylvania Department of Human Services as the repayment for the Medical Assistance benefits provided. It is important to note that these requirements may vary, and it is advisable to consult with an attorney or estate professional familiar with Pennsylvania laws and regulations for a more accurate and comprehensive understanding of the reporting requirements.

What is the penalty for the late filing of pa estate recovery statement?

The penalty for the late filing of a PA Estate Recovery Statement may vary depending on the specific circumstances and the policies of the Pennsylvania Department of Human Services (DHS). However, generally, late filers may be subject to interest charges, fines, or other penalties determined by the DHS. It is recommended to consult with the DHS or a legal professional to get accurate and up-to-date information regarding the penalties for late filing.

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