STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 20TH JUDICIAL CIRCUIT ST. CLAIR COUNTY- IN PROBATE In the Matter of the Estate of ) ) Case No.:______________________ ) _____________________________ ) A Minor ) ORDER TO SETTLE CAUSE OF ACTION ­ MINORS ESTATE On the verified petition of __________________________________________________, guardian of the estate of ____________________________________________, a minor; to settle cause of action for injury, the court having considered the evidence, It is ordered that: 1. The cause of action be settled for $_____________ and, upon receiving that sum, the guardian execute and deliver to the party against whom the cause of action lies a release and discharge from all liability or covenant not to sue on account of the injuries; 2. The guardian distributes the proceeds of the settlement as follows: To _________________________________for hospitalization To _________________________________for medical treatment To _________________________________for bond premium To _________________________________for court costs To _________________________________for To _________________________________for $___________ ____________ ____________ ____________ ____________ ____________ To _________________________________for legal services as to this settlement and distribution (_______% of settlement) ___________________________ (Name of Depository) ____________ To ________________________________ for deposit to the account of the minor until he/ she reaches majority on _________________________, 20_____, or until further order of the court To ______________________________________________________, (Name of Guardian, Parent or Relative) ____________ _____________________________for benefit of the minor. ____________ Total Disbursements $___________ 3. The guardian is excused from filing an inventory and a final account; 4. The court costs shall be _________________________________________________; 5. The guardian shall be discharged from further duty and the guardian and the surety on his bond shall be released from further obligation and the estate closed upon approval of a report of distribution or presentation of vouchers of disbursement in accordance with this order on or before_______________________________________, 20_______. American LegalNet, Inc. www.FormsWorkFlow.com 6. If the guardian fails to present his report of distribution or vouchers, without cause shown the order _____________________costs and allowing the attorney's fee shall be vacated (Releasing or Retaxing) and a rule shall issue against the guardian requiring him to show cause why he should not be adjudged in contempt of court. Dated:________________________, 20___ ENTER: ____________________________________ Judge Name Attorney for Petitioner Address City Telephone American LegalNet, Inc. www.FormsWorkFlow.com