JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 1 of 8 District Court Denver Probate Court County, Colorado Court Address: In the Interest of: Respondent COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division: Courtroom: PETITION FOR APPROVAL OF SETTLEMENT OF CLA IM S PURSUANT TO C.R.P.P. 62 (name), the petitioner, pursuant to Rule 62 of the Colorado Rules of Probate Procedure , petitions the court as follows: Section I Venue, Jurisdiction, and Parties 1. Venue for this proceeding is proper in this county because the respondent: resides in this county. does not reside in this state, but has property in this county. 2. Information about the petitioner: Name: Relationship to respondent: Street address: City: State: Zip c ode: Mailing address, if different: P rimary phone #: Alternate phone #: Email address: 3. Information about respondent: Name: Gender: Age : Date of birth: Street address: City: State: Zip co de: Mailing address, if different: P rimary phone #: Alternate phone #: Email address: American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 2 of 8 4. , partner in a civil union, or adult who has resided with respondent for more than six months within one year before the filing of this petition : Name: Relationship to respondent: Street address: City: State: Zip c ode: Mailing address, if different: P rimary phone # : Alternate phone #: Email address: 5. Information about parents (if respondent is a minor) , legal guardian, custodian, trustee , agent under power of attorney , or court - appointed guardian or conservator : Name: Relationship to respondent: Street address: City: State: Zip c ode: Mailing address, if different: P rimary phone #: Alternate phone #: Email address: Name: Relationship to respondent: Street address: City: State: Zip c ode: Mailing address, if different: P rimary phone #: Alternate phone #: Email address: *Note: If a parent cannot be found, please check the rules on Notice by Publication. Have parental rights been terminated (if respondent is a minor)? Yes No Name of parent(s) whose rights have been terminated: If there is a court - as follows: Section 2 Claims and Liabiliti es 6. The date and a brief description of the event or transaction giving rise to the claim: American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 3 of 8 7. Information about each party against whom respondent may have a claim: Name: Street address: City: State: Zip Code: Mailing address, if different: P rimary phone #: Alternate phone #: Name: Street address: City: State: Zip Code: Primary phone #: Mailing address, if different: P rimary phone #: Alternate phone #: 8. The basis for each of the s are as follows : 9. The defenses and/or counterclaims, if any, to the s are as follows : 10. Information for each insurance company involved in the claim, the type of policy, the policy limits and the identity of the insured : Name of insurance company: Name of insured: Address : City: State: Zip c ode: Contact person: P hone #: Type of policy: Policy limits: Name of insurance company: Name of insured: Address : City: State: Zip c ode: Contact person: P hone #: Type of policy: Policy limits: American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 4 of 8 Section 3 Damages 11. A description of : 12. The amount of time missed by the respondent from school or employment: 13. 14. A summary of any 15. A summary of expenses incurred for medical or other care provider services as a result of the , identification of any source of payment (including person, organization, institution, or st ate or federal agency) for such expenses, and a summary of expenses that have been or will be paid by each particular source : Name of Provider Expenses Expense s Paid Source of Payment (if any) Outstanding Expenses 1 2 3 4 5 5 6 Total $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 5 of 8 Section 4 Medical Status 16. of any disability, disfigurement, or physical or psychological impairments , and any current treatments and/or therapies: Current Physician Letter filed with this Petition : 17. Section 5 Status of Claims 18. For this claim and any other related claim, the status of the claim and if any civil action has been filed, the court, case number, and parties: 19. Information about eac h party having a subrogation right against this claim or any related claim including any state or federal agency paying or planning to pay benefits to or for respondent and the amount of each subrogation : Name of claimant/subrogation holder : Amount of subrogation: $ A ddress: City: State: Zip c ode: P hone #: Name of claimant/subrogation holder : Amount of subrogation $ A ddress: City: State: Zip c ode: P hone #: 20. A s ummary of efforts to negotiate any subrogation rights and liens against this claim or any related claim : American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 6 of 8 Section 6 Proposed Settlement, Payment Terms and Proposed Disposition of Settlement Proceeds 21. Informati on about each party making and receiving payment under the proposed settlement: Name of party/entity making payment : Amount: A ddress: City: State: Zip c ode: Name of party/entity receiving payment: Name of party/entity making payment : Amount: A ddress: City: State: Zip c ode: Name of party/entity receiving payment: Name of party/entity making payment : Amount: A ddress: City: State: Zip c ode: Name of party/entity receiving payment: 22. The s ettlement amount and proposed disposition, including any restrictions on the accessibility of the funds . Description Amount A Gross Settlement Amount $ B Attorney Fees $ C Attorney Costs $ D Payment of Medical Bills per section 15 $ E Payment of Subrogation Claim per section 19 $ F TOTAL PAYOUTS (B+C+D+E) $ G Net Settlement Proceeds (A - F) $ Restrictions, if any: 23. The d etails of any structured settlement , annuity, insurance policy or trust instrument, including the terms and payment structure and the identity of the trustee or entity administering such arrangements: 24. The requested attorney fees and costs to be paid from the settlement proceeds are summarized as follows : American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S Page 7 of 8 25. Whether there is a need for continuing court supervision, the appointment of a fiduciary , or the continuation of an existing fiduciary appointment: 26. The following documents are filed with this petition: Attorney fee agreement Attorney s tatement of costs Attorney b illing records , billing summary or attorney fee affidavit Written statement by physician or other health care provider . (The statement must set forth the information required by C.R.P.P. 62(d)(4) and comply with C.R.P.P. 60 unless otherwise ordered by the court.) Proposed settlement agreement(s) /releases Other: Other: 27. An interpreter is requested for the following person(s): (Language Need(s): ) 28. In addition, the Petitioner requests the following: WHEREFORE, petitioner requests that after notice and hearing, the Court find that the proposed settlement of the claim is in the best interests of the respondent ; find that the Court authorize the acceptance of $ in full settlement of the responde personal injury claim ; a uthoriz e payment of $ to be paid out of the settlement proceeds for any outstanding claims, attorney fees and costs per section 6 ; and authoriz e disposition of the net proceeds of the settlement in the manner set forth in this Petition. By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. American LegalNet, Inc. www.FormsWorkFlow.com JDF 872SC 6 /19 PETITION FOR APPROVAL OF SETTLEMENT OF CLAIM S