4122 Order To Settle Cause of Action - Minor’s Estate (Rev. 8/21/01) CCP 0396 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - PROBATE DIVISION Estate of ________________________________________________________________ Minor } No. ________________________________________ Docket _____________________________________ Page ________________________________________ ORDER TO SETTLE CAUSE OF ACTION - MINOR’S ESTATE On the verified petition of the guardian to settle a cause of action for injury, IT IS ORDERED that: 1. The cause of action be settled for $ _____________________ and, upon receiving that sum, the guardian execute and deliver to the party against whom the cause of action lies a release and discharge from all liability or covenant not to sue on account of the injuries; 2. The guardian distribute the proceeds of the settlement as follows: (Attach additional statement if necessary) Name Description To _____________________________ for ___________________________________ To _____________________________ for ___________________________________ To _____________________________ for ___________________________________ To _____________________________ for ___________________________________ To _____________________________ for ___________________________________ * To ____________________________________________________________________ Amount ________________________ ________________________ ________________________ ________________________ ________________________ (name of depository) IN AN ACCOUNT IN THE NAME OF THE MINOR, TO BE HELD SUBJECT TO FURTHER ORDER OF COURT OR TO BE RELEASED TO THE MINOR WITHOUT FURTHER ORDER UPON THE ATTAINMENT OF MAJORITY ON ________________________ ______________________________________, _________. * To __________________________________________________________________ for benefit of the minor. (name of guardian, parent or relative, stating relationship) Total disbursement ________________________ (4171) $ _______________________ 3. The guardian shall be discharged from further duty and the guardian and the surety on the bond shall be released from further obligation and the estate shall be closed upon the presentation of vouchers of disbursement in accordance with this order on ___________________________________, _________, at ______________ m. in Room ______________. (6133) 4. If the guardian fails to present the report of distribution or vouchers without cause shown, the order approving costs and allowing the attorney’s fee shall be vacated and a rule shall issue against the guardian requiring him to show cause why he/she should not be adjudged in contempt of court. Atty. No.:__________________ Name: ______________________________________________ Atty. for Petitioner: __________________________________ Address: ____________________________________________ City/State/Zip: _______________________________________ ____________________________________, ________ ENTER: ______________________________________________ Judge Judge’s No. Telephone: __________________________________________ *Strike if not applicable. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form