CIRCUIT COURT OF THE SEVENTH JUDICIAL CIRCUIT SANGAMON COUNTY, ILLINOIS ESTATE OF _______________________________________ Deceased } Case No.:_____________________ PETITION TO SETTLE CAUSE OF ACTION-DECENDENT'S ESTATE ___________________________________, administrator of the estate of ___________________________________, deceased, on oath states: 1. Petitioner has a cause of action against ___________________________________________________________________ for causing the death of the decedent on ___________________________________________________________________, 20_____ by reason of (briefly described accident) ___________________________________________________________________________ 2. Decedent's age was ________; his occupation was__________________________________________________________ 3. Decedent left as his only heirs: Name Relationship Percentage of dependency ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. A settlement of $____________________ has been offered and petitioner recommends that it be accepted. 5. The only charges against the proceeds are: ____________________________________________________________ for hospitalization ___________________________________________________________________________ for medical treatment ___________________________________________________________________________ for funeral expenses ___________________________________________________________________________ for court costs ___________________________________________________________________________ for legal service ___________________________________________________________________________ ___________________________________________________________________________ (________________________% of settlement) PETITION TO SETTLE CAUSE OF ACTION-DECEDENT'S ESTATE $ __________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ FORM P-53 American LegalNet, Inc. www.USCourtForms.com For attorney's disbursements (itemize) _____________________________________________________ for ___________________________________________ _____________________________________________________ for ___________________________________________ _____________________________________________________ for ___________________________________________ _____________________________________________________ for ___________________________________________ _____________________________________________________ for ___________________________________________ _____________________________________________________ for ___________________________________________ _____________________________________________________ for ___________________________________________ $ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ TOTAL _________________ _________________ 6. Decedent left no other assets requiring administration. I ask leave to settle cause of action for the sum offered and to distribute the proceeds in accordance with the above proportionate percentage of dependency, and to be discharged as administrator. __________________________________________________ Petitioner Subscribed and sworn to before me ____________________________________, 20_____. ____________________________________________________________________________________________________________ Notary Public CERTIFICATE OF ATTORNEY I certify that I have examined the facts of this case and the applicable law and, in opinion, the proposed settlement is just and proper and that my disbursements were necessary and reasonable. _________________________________________________ Attorney Name_______________________________________ Attorney for petitioner__________________________ Address______________________________________ City_________________________________________ Telephone____________________________________ American LegalNet, Inc. www.USCourtForms.com