Statement of Claim Request Form Statement of Claim Request Form 2025

1. Click ‘Get Form’ to open the Statement of Claim Request Form in our editor.
2. Begin by entering the decedent’s name and last known address prior to entering a nursing home. Ensure accuracy as this information is crucial for identification.
3. Fill in the decedent’s Social Security number, date of birth, and date of death. These details are essential for processing the claim.
4. Indicate the gross amount of the decedent’s estate. Remember to attach any required written documentation that supports this figure.
5. Provide the personal representative’s name, address, and phone number. This individual will be responsible for managing the estate.
6. Next, enter the estate attorney’s details including their name, address, phone number, fax number, and optional email address for communication purposes.
7. Finally, review all entered information for accuracy before submitting it to the Department of Human Services at the provided address.

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