4123 Order For Leave To Settle Cause of Action-Wrongful Death (Rev. 11/2/01) CCP 0354 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, PROBATE DIVISION Estate of _____________________________________________________ Deceased } No. ________________________________________ Docket _____________________________________ Page ______________________________________ ORDER FOR LEAVE TO SETTLE CAUSE OF ACTION-WRONGFUL DEATH On the verified petition of the representative, it appears to the court that: (a) Petitioner has a cause of action against _______________________________________________________________ for causing the death of the decedent on _______________________________, ________. (b) Decedent's next of kin and their proportionate percentages of dependency are set forth in Exhibit A attached hereto. (State name, relationship and percentage of dependency) (c) Petitioner has recommended that a settlement offer of $ ____________________________________ be accepted. * (d) An order was entered by Judge _______________________________ on ___________________________, ________ in Case No. _______________________ approving the settlement and determining the distribution of the proceeds. IT IS ORDERED that: 1. The cause of action be settled for the sum offered and upon receiving the sum offered the representative execute and deliver to the party against whom the cause of action lies a release and discharge from all liability or a covenant not to sue on account of the death. 2. The representative pay charges in the amount of $ _______________________ from the proceeds of the settlement as indicated on Exhibit A attached hereto, which specifies to whom, the purpose and the amount of each charge. q 4178 3. The representative distribute the balance of $ _____________________________ in accordance with the attached percentages of dependency as follows: Name Amount ______________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ 4. This order stands as the representative's final account and the representative shall be discharged, the surety released, and the estate closed upon the presentation of vouchers of disbursement in accordance with this order on _________________________________, __________ at _______________ m. in Room ___________________. q 4139 Atty. No. __________________ Name: ______________________________________________ _______________________________________, _________ Attorney for: ________________________________________ Address: ____________________________________________ ENTER: City/State/Zip: ______________________________________ ________________________________________________ Judge Judge's No. Telephone: _______________________________________ *Strike if not applicable. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS