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Petition To Compromise Doubtful Claim Of Minor Form. This is a Georgia form and can be use in Probate Court Statewide.
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GEORGIA PROBATE COU RT
STAND ARD FORM
Petition to Comprom ise Doubtful Claim of Minor/Ward
INSTRUCTIONS
I.
Specific Instructions
1.
2.
This form may also be used when compromising other than personal injury claims pursuant
to O.C.G.A. §29-3-3, provided appropriate changes are made in the form.
3.
II.
This
form is to be used when petitioning the Probate Court for authorization to
compromise a doubtful personal injury claim of a minor pursuant to O.C.G.A. §29-3-3 or
adult ward pursuant to O.C.G.A. §29-5-23(c)(5). The terms "gross settlement", "net
settlement", and "present value" are defined in O.C.G.A. §29-3-3. This form must be
modified when a covenant not to sue, as opposed to a release, will be executed by the natural
guardian or conservator.
Even if there is a legally qualified conservator, it is not necessary to file a separate petition
to encroach on corpus concerning the expenses listed in paragraph 11 of the form, unless the
court so directs, in which case the prayers listed on page 6 and the provisions of the Order
should be modified.
General Instructions
General instructions applicable to all Georgia probate court standard forms appear in Volume 255
of the Georgia Reports and are available in each probate court.
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GEORGIA PROBATE COU RT
STAND ARD FORM
IN THE PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
, )
)
)
MINOR/WARD
ESTATE NO.
PETITION TO COMPROMISE
DOUBTFUL CLAIM OF MINOR OR
ADULT WARD
TO THE HONORABLE JUDGE OF THE PROBATE COURT:
The petition of
, shows to the Court:
1.
(Initial either a. or b. below):
a.
Petitioner(s) has/have been appointed the conservator(s) of said minor/ward by
Order of this Court, and brings this petition in such capacity.
or
b.
Petitioner(s) is/are the natural guardian(s) of the above minor, the gross settlement
amount is over $15,000.00 but the net settlement amount is less than $15,000.00,
legal action has not been initiated (or, if initiated, has been dismissed with the
approval of the trial judge).
(Initial if applicable:)
The minor/ward currently has cash/personal property in the amount of
$
and will receive additional funds of
$
. As a result of this settlement, the petitioner(s)
will file an additional bond in the amount of $
to secure the minor/ward’s estate.
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2.
Petitioner(s) as natural guardian(s)/conservator(s) has/have claims against
by virtue of an incident occurring on or about
, 20
and who is
. Said minor/ward, whose birth date is
years old, received personal injuries as a result of the following occurrence:
and the minor/ward has potential claim(s) against the following adverse party(ies) not settled in
this action:
.
3.
A copy of the accident report is attached as Exhibit "A".
There was no accident report because
.
4.
The minor/ward sustained the following injuries:
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5.
The minor/ward has been treated by:
6.
The minor's/ward’s physical, mental and emotional condition, as evidenced by the statement of the
treating doctor attached as Exhibit "
", has returned to the condition of said minor/ward prior to such
incident, except for:
7.
The following is a list of all medical expenses and other special damages incurred to date as a result
of the injury to said minor/ward:
8.
The following is a list of all medical expenses and other special damages expected to be incurred in
the future as a result of the injury to said minor/ward as evidenced by the statement of the treating doctor or
doctors attached as Exhibit "
":
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9.
Medical expenses have been paid as follows:
a.
b.
c.
d.
$
by
payment reimbursement insurance coverage. $
coverage remains and will not be released by this settlement.
$
from any group or private insurance sources.
$
as a result of workers' compensation coverage.
$
from any other source (identify).
's medical
of such
10.
Petitioner(s) believe(s) this a fair, reasonable and just compromise because petitioner(s) has/have
fully investigated the facts and circumstances surrounding the incident, and it is uncertain and doubtful that
an amount could be recovered in excess of the settlement amount offered by
, since
the opposing party or parties contend that they are not responsible or liable in any way for whatever injuries
might have been sustained by said minor/ward on the following grounds:
11.
Petitioner(s) and
have
agreed upon a compromise settlement of all claims, which petitioner(s) believe(s) to be fair, reasonable, and
just under the circumstances, upon the terms and conditions set forth below:
a.
b.
c.
d.
e.
f.
Expenses, if any, to be paid from settlement proceeds:
(i)
Attorney's fees
(ii)
Expenses of litigation
(iii)
Medical expenses now due
(iv)
Other (explain below, if necessary)
(v)
Total of such expenses
Cash to conservatorship
(not including above expenses, if any)
(Value) (Cost) of annuity
Gross settlement (total of a., b., and c.)
Net settlement (total of b. and c.)
Further explanation, if necessary:
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$
$
$
$
$
$
$
$
$
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12.
The following is a description and explanation of any amounts being paid to persons other than for
the benefit of the minor/ward as a result of the injuries to said minor/ward:
13.
a.
The adverse party’s(ies’) policy limits of insurance are
.
b.
Uninsured motorists coverage held by
is
contributing $
c.
to the settlement.
There is no policy of insurance involved in this matter.
14.
[To be completed if the claim appears to be worth more than the insurance policy limits:]
Petitioner(s) has/have investigated the assets of the party or parties being released as part of this
settlement, and has/have determined that it would not be worthwhile to decline this settlement offer because:
15.
Petitioner(s) has/have employed
to
represent Petitioner(s) in the prosecution of said minor’s/ward’s claim, and has/have agreed to pay the
attorney’s fees and expenses of litigation in paragraph 11 (a)(i) and (ii) above, which represents
%
of the total settlement.
16.
Petitioner(s) seek(s) to direct settlement proceeds into a structured settlement, and the Disclosures
Regarding Structured Settlement is attached hereto as Exhibit
.
17.
Additional Data: Where full particulars are lacking, state here the reasons for any such omission.
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WHEREFORE, Petitioner(s) pray(s) for an Order approving, and allowing Petitioner(s) to accept,
said offer to compromise and settle upon the terms set forth above; that Petitioner(s) be authorized to
consummate the settlement and execute any and all agreements, receipts, releases and other documents
necessary or proper to effect said settlement; and that Petitioner(s) be authorized to pay from the gross
settlement amount all fees and expenses described in paragraph 11 above.
Signature of first petitioner
Signature of second petitioner, if any
Printed Name
Printed Name
Address
Address
Telephone Number
Telephone Number
Signature of Attorney:
Typed/printed name of Attorney:
Address:
Telephone:
State Bar #
VERIFICATION
GEORGIA,
COUNTY
Personally appeared before me the undersigned petitioner(s) who on oath state(s) that the facts set
forth in the foregoing petition are true.
Sworn to and subscribed before
me this
day of
, 20
.
First Petitioner
NOTARY/CLERK OF PROBATE COURT
Printed Name
My Commission Expires
------------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before
me this
day of
, 20
.
Second Petitioner, if any
NOTARY/CLERK OF PROBATE COURT
My Commission Expires
Effective 7/07
Printed Name
-6-
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Disclosures Regarding Structured Settlement
MINOR/WARD
ESTATE NO.
1.
Total Cost of Structured Settlement:
2.
Annuity
a.
Total payout over life of annuity:
b.
Amount GUARANTEED:
c.
Do payments terminate at death?
d.
Amount of payments: $
i.
Rate of return:
If periodic,
(1)
state period (i.e. monthly)
(2)
ii.
%
Beginning date:
Ending date:
If lump sum distribution at date certain, list,
(1)
$
date
(2)
$
date
(3)
$
date
NOTE: THE ESTATE OF THE MINOR/WARD MUST BE THE NAMED BENEFICIARY TO RECEIVE
ANY GUARANTEED PAYMENTS THAT WILL BE PAID AFTER THE DEATH OF THE
MINOR/WARD. The Petitioner(s) may NOT name themselves as the beneficiary of any assets paid after a
minor/ward’s death, except with Court approval.
3.
List any amounts attorneys will receive AFTER INITIAL SETTLEMENT, IF ANY:
a.
b.
4.
date
date
Name, address, and telephone number of company underwriting the annuity:
Name:
Address:
Telephone
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PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
, )
)
MINOR/WARD
ESTATE NO.
PETITION TO COMPROMISE CLAIM
ORDER APPOINTING GUARDIAN AD LITEM
(to be used if the Petitioner(s) is/are Conservator(s))
A Petition to Compromise Claim being filed by the conservator(s) of the above named
minor/ward, it is hereby
ORDERED that
is appointed guardian ad litem for
the above minor/ward. The deputy clerk shall serve said guardian ad litem with a copy of this Order and
the above Petition/Motion. Upon said guardian ad litem’s acceptance of same, said guardian ad litem
shall make answer hereto.
SO ORDERED this
day of
, 20
.
Probate Judge
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PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
MINOR/WARD
)
)
, )
)
ESTATE NO.
PETITION TO COMPROMISE CLAIM
ANSWER OF GUARDIAN AD LITEM
I hereby accept the foregoing appointment, acknowledge service and notice of the proceedings as
provided by law, and for answer say:
DATE
GUARDIAN AD LITEM
ADDRESS
TELEPHONE
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PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
, )
)
MINOR/WARD
ESTATE NO.
PETITION TO COMPROMISE CLAIM
ORDER
The foregoing petition having been read and considered, and it appearing upon the hearing that the
facts set out in the petition are true and that said settlement is fair, reasonable and just, that the same is made
in good faith, and will be in the best interest of the said minor/ward and will advance the interests of said
minor/ward;
(initial if applicable)
And no objection to the proposed compromise being raised by the guardian ad litem;
IT IS HEREBY ORDERED AND ADJUDGED that Petitioner(s) be and is/are hereby authorized to
consummate said settlement as prayed in said petition, and to execute any and all agreements, receipts,
releases or other documents necessary or proper to effect such settlement, and that such agreements, receipts,
releases or other documents shall constitute the full, final and complete settlement of any and all actions,
causes of action, claims or demands which the above-named minor/ward may have against those parties to
the settlement named in the petition, as fully and completely as if said ward had executed said agreements,
receipts, releases or other documents individually.
IT IS FURTHER ORDERED that Petitioner(s) be and is/are hereby authorized to pay all fees and
expenses shown in paragraph 11 of the petition from the gross settlement amount.
SO ORDERED this
day of
, 20
.
Probate Judge
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