41416FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY Trial Division - Civil1 PLAINTIFF : TERM, 20 : v. : : DEFENDANT : NO: PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION2 To The Honorable, the Judges of the Said Court: The Petition of , a minor, by his Guardian (see Pa. R.C.P. No. 2028), by his attorney, , Esquire respectfully requests: 1) Petitioner is (see Pa. R.C.P. No. 2026):. 2) The minor was born on , and his/her social security number is . 3) The minor resides with at the following address: . 4) A guardian (was) (was not) appointed for the minor as follows: . A copy of the Order is attached. 5) The minor222s parents are who reside at the following address: . 6) The defendant is who resides or whose principal place of business at all relevant times was . 7) On at the following location , the minor sustained the following injuries (set forth in detail): 1 In the event the Petition is filed in the Orphans222 Court Division, the caption must comply with Pa.O.C. 3.2. 2In the event the Petition involves an Incapacitated Person, appropriate changes are to be made. See Pa.R.C.P. No. 2051, et seq. and Phila, Civ. R. 2064. American LegalNet, Inc. www.FormsWorkFlow.com 41416 8) A Complaint was filed against defendant(s) as follows: . 9) Attached hereto is a report by Dr. dated which sets forth the present condition of the minor. 10) Attached hereto is a statement, under oath, of the minor's parents and/or guardian and/or guardian ad litem certifying the physical and/or mental condition of the minor, as well as the parents' and/or guardian's and/or guardian ad litem's approval of the proposed settlement and distribution. 11) Attached hereto is the written approval of the proposed settlement and distribution by the minor, who is sixteen (16) years of age or older. 12) The following settlement has been proposed:3 . (If additional space is needed, please continue on separate page). 13) Counsel is of the professional opinion that the proposed settlement is reasonable due to the following: . (If additional space is needed, please continue on separate page). 14) Counsel has incurred the following expenses for which reimbursement is sought (please set forth in detail) . (If additional space is needed, please continue on separate page). 15) The following costs have been incurred by or on behalf of the minor and must be paid from the proceeds of the settlement: 3Phila. Civ. R. 2039 (D)(5)(f) provides that if there is to be an allocation between adults and minors or among minors, the amounts allocated to each party and specific reasons for such allocation must be set forth. Additionally, if more than one plaintiff is involved, whether minor, adult or incapacitated, Petitioner must set forth the amount each will receive and shall provide justification for the requested allocation. In the event a portion of the settlement is payable through the purchase of an annuity, set forth the credit rating of the entity which assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments. American LegalNet, Inc. www.FormsWorkFlow.com 41416 . (If additional space is needed, please continue on separate page.) 16) The Department of Human Services, or any other entity, does (not) have a claim or lien against the plaintiff(s) as follows . (If additional space is needed, please continue on separate page.) 17) Counsel requests a fee in the sum of $ which is % per cent of the net settlement payable to the minor. A copy of the retainer agreement is attached. 18) Counsel (has) (has not) and (will) (will not) receive collateral payments as counsel fees for representation involving the same matter from third parties (i.e. subrogation). 19) The net settlement payable to the minor (after deduction of costs and attorney222s fees) is $. WHEREFORE, Petitioner requests that he/she be permitted to enter into the settlement recited above and that the Court enter an Order of Distribution4 as follows: a) To $ Reimbursement for Costs b) To $ c) To $ Counsel Fee d) To: Adult Plaintiff(s) (if applicable) $ e) To , A $ Minor,5 in restricted accounts not to be withdrawn before majority or upon prior leave of Court. OR f) To , the Guardian of $ 4Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be 223as per the attached Order224 are not acceptable.5Counsel is cautioned that the restricted account must be set up in the name of the minor only (not in the name of the parent as guardian for the minor). See Pa.R.C.P. No. 2039(b)(2). American LegalNet, Inc. www.FormsWorkFlow.com 41416 the Estate of , A Minor, appointed or to be appointed by the Orphans' Court of County, after posting appropriate security Name of Attorney Attorney for Petitioner American LegalNet, Inc. www.FormsWorkFlow.com 41416 V E R I F I C A T I O N I, , am the Petitioner in this action and hereby verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that the statement in said Petition are made subject to the penalties of 18 Pa. C.S. 2474904 relating to unsworn falsification to authorities. DATE: PETITIONER American LegalNet, Inc. www.FormsWorkFlow.com 41416 FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY Trial Division - Civil : TERM, 20 : : : No. ORDER APPROVING SETTLEMENT AND ORDER FOR DISTRIBUTION AND NOW, this day of , 20 , upon consideration of the Petition For Leave to Compromise A Minor's Action, filed , it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant(s) in the gross sum of ($ ) Dollars. Defendant(s) shall forward all settlement drafts or checks to Petitioners' counsel for proper distribution. IT IS FURTHER ORDERED and DECREED that the settlement proceeds be allocated as follows: 1. To: Minor Plaintiff(s) NAME DOB SS # $ $ 2. To: Adult Plaintiff(s) $ $ IT IS FURTHER ORDERED and DECREED that the settlement proceeds be distributed as follows: 1. Minor Plaintiff6 NAME DOB SS # $ 6The share of each minor Plaintiff shall be separately distributed. American LegalNet, Inc. www.FormsWorkFlow.com 41416 a. To:, Esquire $ Reimbursement of Costs b. To: $ Costs c. To:, Esquire $ Counsel Fees d. The balance, the sum of $ payable to , A Minor, shall be distributed as follows7: OPTION 1 To:, Guardian of the Estate of , A minor; provided, however, that no payment shall be made to the guardian until the guardian has posted additional security as required by the Orphans' Court Division of County pursuant to 20 Pa. C.S. 2475121, et seq. An appropriate Petition shall be filed with the Orphans' Court within thirty (30) days. OPTION 2 Counsel is hereby authorized to execute all documentation necessary to purchase saving certificate(s), from federally insured banks or savings institutions having an office in Philadelphia County, in the sum of $, each not to exceed the insured amount, with the funds payable to the minor upon majority. The certificate shall be titled and restricted as follows: , a minor, not to be redeemed except for renewal in its entirety, not to be withdrawn, assigned, negotiated, or, otherwise alienated before the minor attains majority, except upon prior Order of Court. Counsel shall open a savings account in the sum of $ in the name of the minor. The savings account shall be titled and restricted as follows: , a minor, not to be withdrawn before the minor attains majority, except for the payment of city, state, and federal income taxes on the interest earned by the savings certificate and savings account, or upon prior Order of Court. 7In the event a portion of the settlement is payable through the purchase of an annuity, set forth the credit rating of the entity which assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments. American LegalNet, Inc. www.FormsWorkFlow.com 414162. Adult Plaintiff8 The portion of the settlement payable to , an Adult Plaintiff named in the Complaint, sha