CIV401 State ENG Rev 11/15www.mncourts.gov/formsPage 1 of 2State of Minnesota District Court County of:Select County Judicial District: Court File Number: Case Type: Personal Injury/Minor Settlement Parent/Legal Guardian (first, middle, last)of Minor Petitioner (first, middle, last)Minor Settlement Order This matter came before the Honorable Judge ,Judge of the Judicial District Court on the Petition of parent and legal guardian for the minor, , seekingcourt approval of a settlement with and its insurer . The Court, having reviewed the documentation provided, the court file in this matter, and having heard testimony regarding the settlement, makes the following Order. NOW, THEREFORE, IT IS HEREBY ORDERED:1. The settlement of the above-entitled action in the amount of $ should be and hereby is approved.2. Petitioner is authorized tosign the necessary releases and other documents. 3. The sum of $as payment for attorney's fees and costs owed to (Law Firm) should be and hereby is approved.4. (Law Firm) is directed to pay from its trustaccount the amount of $ to cover the minor's outstanding medical lien that was incurred as a result of the accident.5. (Law Firm) is directed to pay from its trustaccount the amount of $ to purchase a certificate of deposit in the name of American LegalNet, Inc. www.FormsWorkFlow.com CIV401 State ENG Rev 11/15www.mncourts.gov/formsPage 2 of 2the minor, at the (Financial Institution), a Federallyinsured financial institution (FDIC). (Law Firm) is directed to deposit the amount of $ in a(type of account) in only the name of the minor, at (Financial Institution) a Federally insured financial institution (FDIC). Any deposit document shall be issued in only the name of the minor.6. Petitioner and the (Law Firm) shall deliver a copy of the Court's order to the financial institution with the remittance for deposit. 7. Petitioner and the(Law Firm) shall at the time of depositing, supply the minor's social security number to the (Financial Institution).8. Petitioner shall file or cause to be filed, timely state and federal income tax returns on behalf of the minor, as may be necessary.9. The financial institution shall file Form 145.1, with the County Court Administrator within 5 business days of deposit, acknowledging receipt of this Order and the deposit, and that no disbursement of the funds will occur unless the court so orders.10. The financial institution shall not make any disbursement from the account(s), except upon order of the court. The funds shall be placed in a restricted/blocked account and any evidence of deposit shall bear the instruction: 223NO WITHDRAWAL OF PRINCIPAL OR INTEREST, EXCEPT BY ORDER OF THE COURT.22411. The renewal period of the certificate of deposit shall be limited to the date of the age of the minor's majority (date).12. Applications for release of funds, either before or upon the age of majority may be made using the form substantially similar to Form 145.2. BY THE COURT: Judge of District Court Dated: American LegalNet, Inc. www.FormsWorkFlow.com