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 ) PETITION TO SETTLE CAUSE OF ACTION- MINOR'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 reason of (briefly describe accident) _____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. 2. The injuries were:_____________________________________________________________ ____________________________________________________________________________________. 3. The minor was treated at ___________________________________hospital and attended by Dr. ______________________________, whose certificate is attached. 4. Suit ______________ been filed as Case No. _____________in ________________________. (Has or Has not) ____________________________________________________________________________________ 5. A settlement of $___________ has been offered and 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) $_________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ American LegalNet, Inc. www.FormsWorkFlow.com Attorney's 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 reached majority on _________________________, 20______, or until further order of the 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 ________________________________, 20_____ ________________________________________ Notary Public CERTIFICATE OF ATTORNEY 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 Attorney for Petitioner Address City Telephone American LegalNet, Inc. www.FormsWorkFlow.com