Small Estate Affidavit for Medicaid Recovery
State of
County of
Decedent Information
Name of Decedent
Date of Death
Last Residence Address
Medicaid Recipient ID (if known)
Affiant Information
Name of Affiant
Relationship to Decedent
Address
Phone Number
Estate Information
Total Value of Estate
List of Estate Assets
List of Estate Debts
Heirs/Beneficiaries
Names and Addresses of All Heirs/Beneficiaries
Affidavit
Statement:
Date
Signature of Affiant
Notary Public