To notify the issuer of a disclosed annuity of the state's rights as the preferred remainder beneficiary.
Number of Copies
Prepare an original and one copy of Form H0059.
Send the original of Form H0059 to the issuer of the annuity. File the copy in the case record.
Keep the case record copy according to the retention requirements of the case record.
Date — Self-explanatory.
Eligibility Specialist— Self-explanatory.
Office Address and Telephone Number— Self-explanatory.
Addressee — Enter the name and address of the annuity issuer.
Name of Applicant — Enter the applicant's name.
Date of Birth— Enter the applicant's date of birth.
Contract Number — Enter the contract number.