P ETITION TO S ETTLE CAUS E OF ACTION - MINOR S E S TATE 3700 (Rev. 03/05) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT In the Matter of the Estate of CASE NUM BER Minor File Stamp Here PETITION TO SETTLE CAUSE OF ACTION - M INOR S ESTATE , guardian of the estate of , a minor, on oath states: 1. The minor has a cause of action against for injury to him on , 20 by a reason of (briefly describe the accident) 2. The injuries were: 3. The minor was treated at hospital, and attended by Dr. whose certificate is attached. 4. Suit has has not been filed as Case Number in (Court) 5. A settlement of $ has been offered, and the petitioner recommends that it be accepted. 6. The only charges against the proceeds are: for hospitalization $ for medical treatment $ for medical treatment $ for medical treatment $ for court costs $ for bond premium $ for $ for $ for legal services: $ ( % of settlement) CHR IS KACHIR OUBAS, CL ERK OF THE 18TH J UDICIAL CIRCUIT COURT WHEATON, ILL INOIS 60189-0707 >>>> 2PE TITION TO S ETTLE CAUS E OF ACTION - MINOR S ES TATE 3700 (Rev. 03/05) For attorneys disbursements (itemize): for $ for $ for $ for $ TOTAL $ 7. A reasonable amount to be paid to (Name of Guardian, Parent or Relative, stating relationship) for the benefit of the minor is $ 8. is a qualified depository for $ , the balance of the settlement proceeds, to be held for the account of the minor until he reaches majority on , 20 , or until further order of court. Petitioner asks leave to settle the cause of action for the sum offered, to distribute the proceeds and to be discharged as guardian. Signed and Sworn before me this , 20 Notary Public CERTIFICATE OF ATTORNEY t I certify that I have examined the facts of this case and the applicable law and in my opinion the proposed settlement is just and proper and that my disbursements were necessary and reasonable. Attorney Name: PRO SE DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone: CHRIS K ACHIR OUBAS, CLER K OF THE 18TH J UDICIAL CIR CUIT COURT WHEATON, IL L INOIS 60189-0707