Original - Court 1st copy - Probate court Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT JUDICIAL DISTRICT REQUEST FOR APPROVAL OF BOND AND NOTICE SETTLEMENT/JUDGMENT WRONGFUL DEATH SETTLEMENT 2nd copy - Defendant 3rd copy - Plaintiff CASE NO. Court address Court telephone no. Plaintiff name Defendant name Plaintiff's attorney, bar no., address, and telephone no. Defendant's attorney, bar no., address, and telephone no. v Instructions: This form must be used in all settlements/judgments and/or wrongful death settlements when the plaintiff or person receiving a distribution is a legally incapacitated individual, a developmentally disabled person, a protected person, or a minor unless the payment to that minor is for not more than $5,000 in any single year during his or her minority and no conservator has been appointed for that minor. If a settlement/judgment provides for creation of a trust, the trust shall not be funded without the approval of the trust by the probate court in accordance with MCR 2.420(B)(5). Plaintiff's Counsel: After the circuit/district court judge completes the Request, take it to the probate court to obtain written verification that the bond is approved and that the bond, if any, has been filed with the probate court. The Request will be presented to the probate judge assigned to the probate case. Once the probate judge signs the Notice of Bond Approval, the entire form will be returned to you for filing with the circuit/district court. Dispositive orders will be entered by the circuit/district court judge only after the Notice of Bond Approval has been filed. Defense Counsel: Forward the settlement/judgment draft to plaintiff's counsel after you receive a true copy of the judgment, consent judgment, or order of dismissal. REQUEST FOR BOND APPROVAL TO: RE: Name of probate judge assigned to probate case , Name (not the deceased person or the personal representative of the estate) County a legally incapacitated individual a minor Probate case name and file number 1. a. I have conducted a hearing in accordance with MCL 600.2922(6)(a) for the purpose of approving the distribution of funds resolving a wrongful death action. b. I have conducted a hearing in accordance with MCR 2.420(B) for the purpose of approving terms of a proposed settlement. 2. I approved full partial settlement/judgment in the amount of $ . 3. Name of fiduciary , the person serving as the fiduciary (guardian or conservator), is receiving no funds, individually, from the settlement/judgment. is receving $ 4. The fiduciary will receive $ for the estate of Name of legally incapacitated individual or minor after costs and attorney fees. 5. A trust is to be created under the terms of the settlement/judgment. is not to be created. Date Circuit/District judge . , Bar no. NOTICE OF BOND APPROVAL The required bond has been approved by this court and has been filed as appropriate. In lieu of bond, this court has approved a written agreement in regard to use of funds that all assets shall be placed in a restricted account with no withdrawals or transfers to be made without probate court approval. Date MC 95 (3/06) Probate judge REQUEST FOR APPROVAL OF BOND AND NOTICE (SETTLEMENT/JUDGMENT/WRONGFUL DEATH SETTLEMENT) Bar no. MCR 2.420 American LegalNet, Inc. www.FormsWorkflow.com