MC­351 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CASE NAME: ORDER APPROVING: COMPROMISE OF DISPUTED CLAIM COMPROMISE OF PENDING ACTION DISPOSITION OF PROCEEDS OF JUDGMENT Minor Person With a Disability CASE NUMBER: CASE NUMBER: HEARING DATE, IF ANY: DEPT.: has petitioned for court approval of a 1. Petitioner (name): proposed compromise of a disputed claim of a minor or a pending action involving a minor or a person with a disability or a proposed disposition of the proceeds of a judgment for a minor or a person with a disability. 2. Hearing No hearing was held. The petition is an expedited petition under rule 7.950.5 of the California Rules of Court. a. b. Date: Time: Dept.: c. Judicial officer: 3. Relationship to claimant Petitioner has the following relationship or relationships to claimant (check all applicable boxes): a. Parent b. Guardian ad litem c. Guardian d. Conservator e. Claimant, an adult person with a disability, is the petitioner. f. Other (specify): 4. Claimant (name): a. b. is a minor. is a "person with a disability" within the meaning of Probate Code section 3603 who is: (1) An adult. Claimant's date of birth is (specify): (a) Without a conservator. Claimant has capacity to consent to this order, within the meaning of Probate Code section 812, and has consented to this order. A conservatee; a person for whom a conservator may be appointed; or without capacity to consent to this order, within the meaning of Probate Code section 812. A minor described in Probate Code section 3603(b)(3). (b) (2) 5. Defendant The claim or action to be compromised is asserted, or the judgment is entered, against (name of settling or judgment defendant or defendants (the "payer")): Page 1 of 4 Form Adopted for Mandatory Use Judicial Council of California MC-351 [Rev. January 1, 2010] ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Code of Civil Procedure, § 372; Probate Code, § 3500 et seq.; Cal. Rules of Court, rules 3.1384, 7.953 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com MC­351 CASE NAME: CASE NUMBER: 6. THE COURT FINDS that all notices required by law have been given. 7. THE COURT ORDERS a. The petition is granted and the proposed compromise of claim or action or the proposed disposition of the proceeds of the judgment is approved. The gross amount or value of the settlement or judgment in favor of claimant is $ b. Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under Welfare and Institutions Code section 14124.76. The amount shown payable to the Department of Health Care Services in item 7c(1)(d) of this order is the full amount of the lien claimed by the department but is subject to reduction on further order of the court upon determination of the claim for reduction. Payment of fees and expenses Fees and expenses shall be paid by one or more checks or drafts, drawn payable to the order of the petitioner and the petitioner's attorney, if any, or directly to third parties entitled to receive payment identified in this order for the following items of expense or damage, which are hereby authorized to be paid out of the proceeds of the settlement or judgment: (a) Attorney's fees in the total amount of: $ payable to (specify): c. The payer shall disburse the proceeds of the settlement or judgment approved by this order in the following manner: (1) (b) (c) Reimbursement for medical and all other expenses paid by the petitioner or the petitioner's attorney in the total amount of: Medical, hospital, ambulance, nursing, and other like expenses payable directly to providers as follows, in the total amount of: (i) Payee (name): (A) Address: (B) Amount: $ (ii) Payee (name): (A) Address: (B) Amount: $ $ $ Continued on Attachment 7c(1)(c). (Provide information about additional payees in the above format.) (d) Other authorized disbursements payable directly to third parties in the total amount of: $ (Describe and state the amount of each item and provide the name and address of each payee): Continued on Attachment 7c(1)(d). (e) MC-351 [Rev. January 1, 2010] Total allowance for fees and expenses from the settlement or judgment: $ Page 2 of 4 ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC­351 CASE NAME: CASE NUMBER: 7. THE COURT ORDERS (cont.) c. The payer shall disburse the proceeds of the settlement or judgment approved by this order in the following manner: (2) Balance The balance of the settlement or judgment available for claimant after payment of all allowed fees and expenses is: The balance shall be disbursed as follows: (a) $ By one or more checks or drafts in the total amount of (specify): $ drawn payable to the order of the petitioner as trustee for the claimant. Each such check or draft must bear an endorsement on the face or reverse that it is for deposit in one or more interest-bearing, federally insured accounts in the name of the petitioner as trustee for the claimant, and no withdrawals may be made from the accounts except as provided in the Order to Deposit Money Into Blocked Account (form MC-355), which is signed contemporaneously with this order (''blocked account"). By the following method(s) (describe each method, including the amount to be disbursed ): (b) Continued on Attachment 7c(2)(b). (c) If money is to be paid to a special needs trust under Probate Code section 3604, all statutory liens in favor of the state Department of Health Care Services, the state Department of Mental Health, the state Department of Developmental Services, and any city and county in California must first be satisfied by the following method (specify): Continued on Attachment 7c(2)(c). 8. Further orders of the court concerning blocked accounts The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked account under item 7c(2)(a): a. Within 48 hours of receipt of a check or draft described in item 7c(2)(a), the petitioner and the petitioner's attorney, if any, must deposit the check or draft in