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Effective Date: 




Updated: 7/2020



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.


Detailed Instructions

Date — Self-explanatory.

Eligibility Specialist— Self-explanatory.

Office Address — Self-explanatory.

Phone 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 No. — Enter the contract number.