! 0017 ! 1017 Jury Demand Petition to Settle Cause of Action-Wrongful Death (Rev. 7/26/01) CCP 0353 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - PROBATE DIVISION Estate of _______________________________________________________ Deceased } No. ________________________________________ Docket ___________________________________ Page ____________________________________ PETITION TO SETTLE CAUSE OF ACTION-WRONGFUL DEATH _____________________________________________________________________________, representative of the estate, on oath states: 1. Petitioner has a cause of action against ______________________________________________________ for causing the death of decedent on ____________________________, ________. 2. Decedent's next of kin and their proportionate percentages of dependency are set forth on Exhibit A attached thereto. (State name, relationship and percentage of dependency) 3. A settlement of $ ______________________________ has been offered and petitioner recommends that it be accepted. *4. An order was entered by Judge _______________________________________ in case No. ______________________ approving the settlement and determining the distribution of the proceeds. (Attach copy of order) 5. The total charges against the proceeds in the amount of $ __________________________ are listed on Exhibit A attached hereto. (Specify to whom, purpose, and amount of each charge) 6. The balance available for distribution is $ _______________________ to be paid in accordance with the above percentages of dependency, as follows: Name Amount _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 7. Decedent left no other assets requiring administration. Petitioner asks leave to settle the cause of action for the sum offered, to pay out the proceeds, and to be discharged as representative. _________________________________________________ Petitioner Signed and sworn before me on this day of _________________________________________, ________ Atty. No. __________________ Name: ______________________________________________ Attorney for Petitioner: _______________________________ ______________________________________ Notary public Address: ____________________________________________ City/State/Zip: _______________________________________ Telephone: _________________________________________ *Strike if not applicable DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form