NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY(S) ATTORNEY(S) FOR SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF CONTRA COSTA DISPUTED CLAIM OF CASE NUMBER PDEPT. NO. ORDER APPROVING COMPROMISE OF MINOR'S CLAIM Under Section 1431 P.C. (NO ACTION PENDING) A MINOR Honorable Judge presiding Date of Hearing: Attorney(s) appearing for petitioner(s) The Petition of hereinafter called "petitioner," for approval of the proposed compromise of the claim of the above named minor against coming on regularly to be heard, upon the evidence introduced, the Court finds that the facts set forth in said petition are true and that it is for the best interests of the minor that said claim be compromised and settled for the amount hereinafter stated and that the proceeds for such settlement be paid and used in the manner hereinafter specifically provided: IT IS THEREFORE ORDERED: A. That said compromise be and is hereby approved and that upon payment of the sum of $ (being the total amount of the settlement sum herein approved) in the manner herein provided, the payor shall be fully and forever released and discharged of and from all claims, charges and demands of said minor arising from the accident mentioned in said petition; B. Payor shall disburse the proceeds of the settlement hereby approved in the following manner: (1) By one or more checks or drafts drawn payable to the order of petitioner and/or the respective parties entitled to receive payment of the following items of expense or damage which the petitioner is hereby authorized and directed to pay out of the proceeds of settlement: (a) Attorneys' fees hereby fixed and allowed to (b) Reimbursement to petitioner for medical and other expenses paid by petitioner $ (c) Unpaid medical, hospital ambulance, nursing and other like expenses not reimbursable to petitioner from insurance or other funds MUST BE PAID BY CHECKS OR DRAFTS to each of the following parties: $ (Over) ORDER APPROVING COMPROMISE OF MINOR'S CLAIM (No Action Pending) H263 5M 8/77 CC-263 2000 (C) American LegalNet, Inc. Total Total (d) $ ...................................... $ ..................................... Other (specify) GRAND TOTAL OF ALLOWANCES FOR FEES AND EXPENSES $ ..................................... (2) By check or draft drawn payable to the order of petitioner as trustee for said minor, and *............................................................................................................................................................................................... ....................................................................................................................................................................... and bearing an endorsement on the face reverse side of such check draft to the effect that same is for deposit to the account of said petitioner as trustee for said minor, in the amount of $ ............................................................... Within 48 hours after receiving the check or draft mentioned in this Paragraph B (2), petitioner shall deposit same in petitioner's name as trustee for said minor in .......................................................................................................................................................... Branch, and shall deliver to said depositary two (2) copies of the Order to Deposit Money, which order is being signed contemporaneously herewith. Petitioner shall make no withdrawal from said account without first obtaining an order of this court authorizing same. Bond is hereby waived. C. Upon receipt of the full amount of the settlement sum herein approved, petitioner is hereby authorized and directed to execute and deliver to said payor a full, complete, and final release and discharge of sand from any and all claims and demands of said minor by reason of the accident described in said petition and the resultant injuries and damages to said minor. ........................................... (Date) ..................................................................................................... Judge of the Superior Court * Name of Depositary 2000 (C) American LegalNet, Inc.