Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Infants Compromise Order A Structured Settlement (Simple Order) Form. This is a New York form and can be use in Bronx Local County.
Loading PDF...
Tags: Infants Compromise Order A Structured Settlement (Simple Order), New York Local County, Bronx
FORM – SIMPLE ORDER FOR A STRUCTURED SETTLEMENT
At an IAS Part
of the Supreme Court of
The State of New York, held in and for the
County of Bronx, at the Courthouse thereof,
on the
day of
, 20
.
Present: Hon. Paul A. Victor, J.S.C.
x
Index No.
COMPROMISE ORDER
FOR A STRUCTURED SETTLEMENT
Plaintiff(s)
-against-
Defendant(s)
x
Upon the application of plaintiff’s counsel for judicial approval for a structured
,
settlement and upon reading and filing the petition of
parent and natural guardian of the infant herein, duly sworn to the
the affidavit of
day of
, 20
;
, the infant plaintiff, duly sworn to the
day of
, 20
attorney for plaintiff(s), dated the
of
; the affirmation of
day of
, M.D., dated the
affirmation of
,
, 20
; the affirmation/report
day of
, 20
; the
, a structured settlement broker, dated the
, 20
day of
; and upon all of the exhibits, papers, pleadings and proceedings
heretofore had herein, and/or attached hereto; including, without a limitation thereto, the
following documents and proposed implementing agreements: Settlement Agreement [Ex.A];
Assignment Agreement [Ex.B]; Annuity Contract [Ex.C]; and Guaranty Agreement [Ex. D]; and such
other exhibits as identified in the above supporting affidavits and/or affirmations; and
WHEREAS the plaintiff(s) and the defendant(s) seek judicial approval for a structured
settlement and to settle this action for the sums set forth in decretal paragraph 1; and
WHEREAS it is the intention of the parties to comply with all the requirements of section
104 and 130 of the Internal Revenue Code, relating to a structured settlement; and.
WHEREAS plaintiff has been advised to obtain independent professional advice relating
to the legal, tax and financial implications of the settlement; and has received all information
required by §5-1702 of the General Obligations Law, including the amounts and due dates of the
American LegalNet, Inc.
www.FormsWorkflow.com
periodic payments to be made; the amount of the premium payable to the annuity issuer; the nature
and amount of any cost that may be deducted from any periodic payments; and the prohibitions
against transfer of the periodic payments; and
STRUCTURED SETTLEMENT TOTAL COST
WHEREAS the plaintiff(s) and the defendant(s) have agreed upon the sum of
$
as the total cost of the settlement to defendant(s) (the “Total Settlement
Cost”); and
WHEREAS the Total Settlement Cost is comprised of up-front money totaling
$
, plus $
to fund the purchase of an annuity contract
that will make the periodic payments set forth below, and
STRUCTURED SETTLEMENT PAYOUT
WHEREAS, based on plaintiff’s normal life expectancy set forth below, it is expected
(“Total Settlement
that plaintiff will receive a total settlement payout of $
Payout”), consisting of the up-front money totaling $
payments totaling $
WHEREAS, $
plus future periodic
(all of which are set forth in decretal paragraph 1); and
of the above total future periodic payments are guaranteed
payments (i.e., payments that are payable regardless of whether the plaintiff is alive); and
THE ASSIGNMENT, ANNUITY ISSUER AND GUARANTOR
WHEREAS the defendant(s) propose(s) to assign the liability to make the aforesaid periodic
payments to an “assignee” company, which will purchase an annuity contract from the hereinafter
described annuity issuer, which is licensed to do business as a life insurance company in the State of
New York, and which is rated A++ or A+ by A. M. Best Company; and
WHEREAS said “assignee” company will have its obligation to make said future periodic
payments guaranteed by the hereinafter described “guarantor”; and
LIFE EXPECTANCY AND DATE OF BIRTH
WHEREAS the infant plaintiff is now
years of age, having been born on
; and based on normal life expectancy is expected to live to the age of
years; and
THE HEARING
WHEREAS the (petitioner/the mother and natural guardian) and the (infant/impaired person)
plaintiff and their attorney having appeared before me on the
day of
, 20
;
and it appearing that the best interests of the infant will be served by approval of this proposed
American LegalNet, Inc.
www.FormsWorkflow.com
settlement;
NOW THEREFORE, it is
1.
ORDERED, that the plaintiff(s) and the defendant(s) be, and hereby are, authorized and
empowered to execute a settlement agreement to settle this action for a total payout consisting of the
up-front sum of $
, (as apportioned in paragraph 2 (A) below) plus the following
periodic payments:
(A) The sum of $_____________ per month for the life of the infant
plaintiff [increasing by
% per year compounded annually], for a guaranteed
minimum of
years with the first payment on _________________________
and the last guaranteed payment on __________________________; and
(B) A guaranteed payment of $___________ on
; and
(C) A guaranteed payment of $___________ on
; and
(D) A guaranteed payment of $___________ on
; and
(E) A guaranteed payment of $___________ on
; and
(F) A guaranteed payment of $___________ on
; and
(G) A guaranteed payment of $___________ on
; and
(H) A guaranteed payment of $___________ on
; and
(I) A guaranteed payment of $___________ on
; and
(J) A guaranteed payment of $___________ on
; and
(K) A guaranteed payment of $___________ on
; and
all of which said periodic payments shall be made payable to (here name the payee); and it is further
2. ORDERED, that the Total Settlement Cost of $_____________________________ shall be
paid by the defendants, within 20 days of the service of this signed order as follows:
UP-FRONT MONEY
(A)(1) The sum of $__________ to the order of _______________the attorneys for the
plaintiff as and for attorneys' fees, inclusive of all disbursements and expenditures
made on plaintiff’s behalf; and
(2) The sum of $__________ to the order of said attorneys for plaintiff as and for
disbursements and expenditures made on behalf of the plaintiff; and
(3) The sum of $__________ to the order of ________________________________,
in full satisfaction of the outstanding lien for services rendered and/or money
advanced to said plaintiff; and
(4) The sum of $_________ to the order of ________________________the parent and
natural guardian of the said infant, jointly with an officer of the
American LegalNet, Inc.
www.FormsWorkflow.com
______________________________________________________________________
______________________________________________________________________
Bank, located at ________________________________________________;
said funds to be deposited in said Bank and held therein for the sole use and benefit
of said infant, subject to the further order of this Court, and
COST OF ANNUITY
(B) The sum of $_______________ to the order of _________________________ to fund
the purchase of a structured settlement annuity which will provide the periodic
payments described in paragraph 1 above; and it is further
3.
ORDERED, that the defendant (the “Assignor”), shall make a qualified assignment
under Section 130 of the Internal Revenue Code to
______________________________________(the “Assignee”) of the Assignor’s obligation to
make the periodic payments set forth in Paragraph 1; and it is further
4.
ORDERED, that aforesaid Assignee shall fund its obligation to make such periodic
payments by the purchase of an annuity contract at a cost of $
from
(the “Annuity Issuer”),
which is licensed to do business as a life insurance company in the State of New York, and which
is rated
by A.M. Best Company; and it is further
5.
ORDERED that in accordance with the terms of said assignment, the aforesaid
Assignee shall be substituted as obligor of such periodic payments for the Assignor, which shall
be released from any further obligation to make said periodic payments; and it is further
6.
ORDERED, that the obligations of the Assignee to make the periodic payments shall
be guaranteed by
7.
(“Guarantor”); and it is further
ORDERED, that none of the above described obligors and guarantors, nor the infant,
nor his/her guardian, nor any payee may sell, assign, pledge, transfer or encumber the annuity
benefits hereinabove described or take any other action to defeat or impair the intent of this Court
to provide to the infant plaintiff the payments hereinabove set forth, absent a further order of the
Court; and it is further
8.
ORDERED, that plaintiff’s attorney shall serve upon the plaintiff, a copy of this
executed order and all supporting papers, as well as a copy of the final and executed structure
documents (including the annuity contract, the settlement agreement, the assignment agreement,
and the guarantee agreement); and counsel shall file a copy of all of the above with the office of
the Clerk for the Court, together with proof of service of same; and it is further
9.
ORDERED, that aforesaid depository Bank which, pursuant to this Order, receives
American LegalNet, Inc.
www.FormsWorkflow.com
funds jointly with the parent and natural guardian of the infant, shall place said funds in the
highest interest bearing time accounts or certificates of deposit, and said certificates and
accounts shall be renewed upon maturity, provided, however, the maturity date of such
certificates and accounts or any renewal thereof, shall not extend beyond the date of the infant’s
eighteenth (18th) birthday; and it is further
10. ORDERED, that the attorney for the plaintiffs shall serve a copy of this Order upon
said Bank and shall arrange for the deposit of said funds as expeditiously as is reasonably
possible; and it is further
11. ORDERED, that within thirty (30) days of the deposit of said funds in the abovedesignated bank(s) the above guardian shall submit to the Office of the Clerk for the Court, a
copy of each certificate of deposit(s) issued by said bank(s); and there shall be no right of
withdrawal from any of the aforesaid account(s) and certificates of deposit until the infant
plaintiff’s eighteenth (18th) birthday, except upon further order of this Court, which said Order
shall be certified by the Clerk of this Court; and it is further
12. ORDERED, that in the event that the amount on deposit at any Bank exceeds the
then prevailing Federal Deposit Insurance Corporation limits, the officer-trustee of said Bank and
the infant’s guardian herein are directed to notify the Court so that a further designation of an
additional depository may be made in order to keep the amount within federally insured limits;
and it is further
13. ORDERED, that said Bank shall pay over all monies held in the aforesaid certificates
and accounts to the infant plaintiff herein upon demand and without further Court order when the
infant reaches the age of eighteen (18) years upon presentation of proper proof and compliance
with the Bank rules of withdrawal; and it is further
14. ORDERED, that each year (or quarterly as the case may be) during the minority of
the infant plaintiff, upon presentation to the above Bank of a duly executed income tax return or
other document showing the amount of income tax or estimated income tax due on behalf of the
infant, said Bank shall provide the infant’s guardian herein with checks made payable to the
Internal Revenue Service and/or State and/or Municipal Taxing Authority to which said income
tax is owed by said infant. However, said checks shall be only for the amounts as may be due
and payable for that portion of the infant’s personal income tax liability attributable to income
earned on the accounts maintained pursuant to this Order [including interest and penalties
thereon] as shown on any official bill therefor issued by the taxing authority. Said checks shall
identify the infant and said infant’s social security number in order to insure that said amounts
are being made for the benefit of the infant; and it is further
American LegalNet, Inc.
www.FormsWorkflow.com
15. ORDERED, that the above Bank is hereby authorized without further order of this
Court to pay out of the infant’s bank accounts, reasonable fees for the preparation of any income
tax return or estimated income tax return or accounting that may be required to be filed by or on
the infant’s behalf. Said fees shall not exceed $ ____________ without the further order of the
Court; and it is further
16. ORDERED, that in the event of the death of said infant plaintiff prior to the date of
any guaranteed periodic payment, all sums shall be paid to the estate of said infant plaintiff
unless, upon reaching the age of 18, the infant plaintiff has changed his designated beneficiary, in
which event said sums shall be paid to said designated beneficiary; and it is further
17. ORDERED, that the cause of action for loss of services and/or medical expenses of
the guardian be and the same hereby is dismissed without costs and with prejudice; and it is further
18. ORDERED, that conditioned upon compliance with the terms of this order, the
aforesaid parent and natural guardian of the infant plaintiff, be and hereby is authorized and
empowered to execute and deliver a general release and all other instruments necessary to
effectuate the settlement herein; and it is further
19. ORDERED, that upon the payment of the amounts set forth in paragraph 2 and
execution of the settlement agreement and the assignment agreement, defendant and its insurer
shall have no further liability herein; and it is further
20. ORDERED, that if it appears that any government agency may attach a lien to the
infant’s payment, this Order may be amended to allow the creation of a Supplemental Needs
Trust for the benefit of the infant and the Supplemental Needs Trust will be substituted as the
payee of the payments.
21. ORDERED, that the filing of a bond be dispensed with in accordance with the
applicable provisions of the Civil Practice Law and Rules.
Date
Hon. Paul A. Victor, J.S.C.
American LegalNet, Inc.
www.FormsWorkflow.com
INSTRUCTIONS
______________________________________________________________________
FOR THE SIMPLE ORDER FOR A STRUCTURED SETTLEMENT
_______________________________________________________________
__________________________
The Court’s Rules and Forms
This form is designed for settlements where there is more than one defendant (and its insurer),
participating in the settlement and in the funding of the purchase of the annuity. If there is a
different number of defendants, or more than one annuity is being purchased, the form must be
modified accordingly; or the alternate form order (for complex settlements), should be used.
Before completion and submission of the application to settle a claim or action of an
infant or impaired person, counsel is cautioned to read the court’s rules and to use the court’s
forms; all of which are available on the OCA website. If counsel has any question, or is unsure
of how to proceed, counsel is invited to call Chambers and arrange for an appointment to discuss
the matter before an application is filed.
After a hearing has been concluded you will be required to serve a copy of the proposed
structured settlement order on all defendants and insurance carriers, with a Notice of Settlement
so that they will have an opportunity to be heard and object before being bound by its terms.
Note: only the proposed order need be served, not the underlying supporting papers.
Preamble (Whereas) Clause
The terms of the settlement and other relevant information and requirements are outlined
in the “Whereas” clauses. Note: This form complies with the requirements of the Internal
Revenue Code and explains in its opening ”Whereas” clauses, the significant difference between
the “Total Settlement Payout” and the “Total Settlement Cost.” Decretal Paragraph 1 has been
specifically designed to comply with Internal Revenue Code requirements and should not be
modified (except however, to conform it to the specific periodic payments proposed in this
application). Note, that when all future periodic payments are guaranteed, the amount set forth in
the Whereas Clauses for “future periodic payments” and for “guaranteed periodic payments” will
obviously be identical. However, if any of the future periodic payments will terminate upon
death, the above amounts will be different. In any event, the whereas clauses can be modified
accordingly.
All information set forth in the proposed “Order” must be supported by the underlying
affidavits and affirmations as well as in the required exhibits. The proposed implementing
structured settlement documents must be appended as exhibits to the application. These exhibits
must identify all the necessary parties thereto as well as the annuity payout being proposed.
A structured settlement plan will be approved by the court after a hearing has been
American LegalNet, Inc.
www.FormsWorkflow.com
conducted. In most instances defendants insist that a structure plan be provided by a structure
broker that is selected by defendant and/or its insurer. The Court requires that plaintiff’s counsel
retain a structure broker before discussing a structured settlement with the defendants, [See, City
Part Rules for Settlement of Claims By Infants and Impaired Persons]. Both brokers can be
compensated by a splitting of the annuity commission so there is no cost to the plaintiff or the
attorney. If there is a dispute regarding commissions, request a hearing and request or subpoena all
necessary persons to be present.
The application to settle the claim must be supported by an affidavit by the structure broker
whose structure plan is recommended to the court by plaintiff’s counsel to be best for the
infant/impaired person. This affidavit must conform to the form affidavit provided by this court
on the OCA website. After a hearing and review of all submitted plans, and all circumstances
leading up to the proposed plan, the court will select and approve one of the plans as well
as determine the appropriate apportionment of commissions..
Decretal Paragraph No. 1
Modify the form to comport with the proposed periodic payments which are described in
the underlying documents, but do not otherwise modify the format since this paragraph was
designed to comply with Internal Revenue Code requirements.
The Guarantees
The “guaranteed” payments mentioned in this paragraph (as well as in the preamble
“Whereas” clauses) refer to that part of periodic payments that will not terminate upon the death of
the infant/impaired person. Upon death, these “guaranteed” payments will be made to the estate of
the infant/impaired person, or to the designated beneficiary of said person. The “guarantee”
mentioned in this paragraph is not to be confused with the guaranty which is provided by a
“guarantor” company which will guarantee the obligation of the assignee company to make all of
the future periodic payments [See, decretal paragraph No. 6]. Nor should the guarantee mentioned
in decretal paragraph 1 be confused with the additional guaranty provided under New York
Insurance Law, Article 77.
Under N.Y. Ins. Law Article 77, the Life Insurance Company Guaranty Corporation of
New York provides $500,000 of protection with respect to an annuity in the event an annuity issuer
becomes insolvent if the annuity issuer is licensed in New York and the plaintiff is a New York
resident. See N.Y.S. Ins. Dept. O.G.C. Opinion 95-65 (9/24/95); See also N.Y.S. Ins. Dept.
O.G.C. Opinion 5-1-96 (May 1, 1996), General Counsel Opinion 2-20-2003 (February 20, 2003).
In view of this, where the amount structured is more than $500,000, it is prudent, but not required
by law, to purchase annuities from more than one issuer to keep the cost of each annuity below
American LegalNet, Inc.
www.FormsWorkflow.com
$500,000. The court is informed, however, that purchasing more than one annuity generally results
in lower payments to the plaintiff.
The Payee
At the end of decretal paragraph No. 1, insert the name of the “payee.” Here you should
insert the name the infant plaintiff individually if payments commence on or after infant’s 18th
birthday. If payments commence before the 18th birthday or if payments are to an impaired person,
provisions must be made for payments to the parent or guardian together with a Bank Officer; or to
a guardian appointed pursuant to Article 81 of the Mental Health Law. In cases where an infant or
impaired person is receiving , or may in the future receive, needs based governmental benefits,
such as Medicaid or Supplemental Security income, Counsel should consider making provision
for, and the order should provide for, the creation of a Supplemental Needs Trust to preserve
eligibility for such benefits, in which event the trust should be named as the payee in this
paragraph.
Decretal Paragraph No. 2
Paragraph (A) sets forth the up-front money to be paid by defendants, to cover the costs
for plaintiff’s counsel fees, disbursements, liens and up front money to the plaintiff, if any. If
other up-front money must be added, the form should be modified accordingly. Paragraph (B)
provides for the payment by defendant to fund the purchase of an annuity which will provide the
future periodic payments. If this defendant is purchasing more than one annuity, then an
additional subparagraph should be added for each payment toward an annuity.
Decretal Paragraphs No. 3 And 4
The “Assignor, The “Assignee” and The “Annuity Issuer”
The defendant (or its insurer), the “assignor”, usually assigns the obligation to make the
periodic payments to an “assignee” company, which is usually a shell affiliate of the annuity issuer.
That “assignee” company will then purchase the annuity contract from the annuity issuer.
The “annuity issuer” must be licensed to do business in the State of New York, in order for
the annuity to be protected by the Life Insurance Company Guaranty Corporation of New York
discussed above, and it should have an A.M. Best Company rating of no less than A++ or A+,
which are the two highest ratings. The ratings of the proposed annuity issuer must be described in
the broker’s affidavit and must be supported by an appropriate exhibit attached thereto.
American LegalNet, Inc.
www.FormsWorkflow.com
The “Settlement Agreement” and the “Assignment Agreement”
The “Settlement Agreement” and the “Assignment Agreement” will provide among other things, that
the defendant (or its insurer) will assign the obligation to make the future periodic payments to an assignment
company which is usually an affiliate of the annuity insurer. In decretal paragraph No.3, that assignment
company (the “assignee”) must be identified, and in decretal paragraph No. 4, the life insurance company (the
“annuity issuer”) and its A.M. Best Company rating must be set forth.
The Court’s Rules for a structured settlement require a copy of each of the proposed agreements to be
submitted as exhibits to the structured settlement broker’s affidavit, which is submitted in support of the
application to settle the claim or action. There is no standard form of “settlement agreement.” However, there
are several forms of assignment agreements generally used in structured settlements. The plaintiff should
request that the form known as the Uniform Qualified Assignment, Release and Pledge Agreement be used,
since it grants the plaintiff a security interest in the annuity. Most annuity issuers will use such a form, if
requested. If the annuity issuer does not offer a security interest, then the “Uniform Qualified Assignment and
Release Agreement” must be used, and the plaintiff will be a general, unsecured creditor of the Assignee.
Please note, that decretal paragraph No.8 of the order requires, among other things that, after all of the
documents have been signed, a copy of each must be provided to plaintiff by plaintiff’s counsel; and proof of
service of same must be filed with the Clerk of the Court.
Decretal Paragraph No. 6
The “Guarantor”
Here insert the name of the “guarantor” company. The obligations of the “assignee” company to make
the periodic payments are guaranteed by the annuity insurer or by a substantial affiliated company unless the
assignee is a substantial company.
Notice of Settlement
After a hearing has been conducted you will be required to serve a copy of the proposed structured
settlement order on all defendants and insurance carriers, with a Notice of Settlement so that they will have
an opportunity to be heard and object before being bound by its terms. Note: only the proposed order need be
served, not the underlying supporting papers.
The order will be signed on the “settlement”date, if no issue or objection has been raised by the
defendant or the insurance carriers involved in the transaction.
Compliance With Remainder Of Decretal Paragraphs
Counsel should carefully read and implement the remainder of the decretal paragraphs after the order
has been signed. The order will be signed on the “settlement date” if no issue or objection has been raised by
American LegalNet, Inc.
www.FormsWorkflow.com
the defendant(s) or the insurance carriers involved in the transaction.
Counsel should take special notice of the obligations imposed by decretal paragraphs No. 8 and 11
which, among other things, require service of the documents on plaintiff, and the filing of the documents
with the Clerk for the Court, with proof of compliance.
American LegalNet, Inc.
www.FormsWorkflow.com