For Office Use Only Filing Fee Paicj $ Receipt No.: DO NOT LEAVE ANY ITEMS BLANK SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS -------------------------------------------------------------X PROCEEDING BY AS ADMINISTRATOR OF THE ESTATE OF Deceased, TO LIFT RESTRICTIONS. ---------------------------------------------------------------X TO THE SURROGATE'S COURT, COUNTY OF QUEENS: PETITION TO LIFT RESTRICTIONS File No. The petition of , Administrator of the Estate of ------------' duly appointed on and residing at --------------------------respectfully shows: 1. That the decedent died on -------' a resident of Queens County and the State of New York. 2. On Limited Letters of Administration were issued by this Court to the petitioner restricting him or her from collecting or receiving any funds or other property of the decedent in excess of$ without further Order of the Surrogate. 3. The names and addresses of all distributees interested in this proceeding, and the date of birth of all infant distributees, are as follows: -1- American LegalNet, Inc. www.FormsWorkFlow.com 4. The names and addresses of all creditors and lien holders and the amount of the debt or lien are as follows: 5. On ----------an action for the wrongful death of the decedent: o was settled in the amount of$ ; or o was terminated as a result of a verdict and judgment was entered in favor of the decedent in the amount of$ 6. Pursuant to the terms of the attached copy of the retainer agreement and the attached itemized list of disbursements, attorney's fees are requested for the prosecution of the action for wrongful act, neglect or default in the amount of$ and disbursements are requested in the amount of$ WHEREFORE, the petitioner respectfully prays that: (1) the restrictions as listed on the Limited Letters of Administration granted by the Court be modified to permit the collection of the funds recovered from the wrongful death action above; (2) Upon collection, the settlement funds shall be deposited in an interest bearing escrow account for the benefit of the decedent and distributees; (3) That attorneys fees in the sum of and reimbursement of disbursements in the sum of , for a total of be fixed and approved; (4) The attorney for the administrator or personal representative shall pay from the account all due and payable expenses set forth above as well as Court approved legal fees and disbursements; (5) The attorney for the administrator or personal representative shall continue to serve as the attorney for said administrator or personal representative until the entry of a final decree in a proceeding to compromise and account in this Court. (6) All other restrictions shall remain in effect. Dated: ------------ Petitioner's Name (Printed) Petitioner's Signature -2- American LegalNet, Inc. www.FormsWorkFlow.com Verification: I have read the foregoing petition subscribed by me and know the contents thereof, and the same is true of my own knowledge, except as to matters therein stated to be alleged upon information and belief, and as to those matters I believe it to be true. State of New York ) County of Queens ) )ss.: Petitioner's Signature On the day of , 20, before me, the undersigned, a Notary Public in and for said State, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument. Such person duly swore to such instrument before me and duly acknowledged to me that he/she executed the same. Notary Public Name of Attorney: Tel,. No.: Address of Attorney: -3- American LegalNet, Inc. www.FormsWorkFlow.com Present: HON. PETER J. KELLY, Surrogate ----------------------------------------------------------------------------->< PROCEEDING BY ------------- AS ADMINISTRATOR OF THE ESTATE OF Deceased, TO LIFT RESTRICTIONS. -----------------------------------------------------------------------------)( At the Surrogate's Court held in and for the County of Queens, at Jamaica, State of New York, in said County on the day of , 20. ORDER File No .. A duly verified petition dated having been filed by ----------------praying for an Order modifying the limitations on the Letters of Administration to allow the collection of $ which represents the total proceeds of a wrongful death cause of action brought on behalf of the decedent, it is hereby ORDERED that the Letters of Administration be modified to allow the collection of $ which represents the total settlement of the cause of action; and it is further ORDERED that, upon the collection of the funds set forth above and the creation of an interest255bearing escrow account for the benefit of the distributees, the attorney for the administrator or personal representative shall pay from the account all due and payable expenses as set forth in the petition; and it is further ORDERED that attorney's fees are approved for the prosecution of the action for wrongful act, neglect or default, in the amount of $ , along with disbursements in the amount of $ which shall be immediately payable from said escrow account after payment of the expenses set forth above; and it is further ORDERED that the attorney for the administrator or personal representative shall file a petition for the allocation and distribution of the above proceeds in this Court, and cause a citation to issue to all necessary parties within days from the date of this Order; and it is further ORDERED that the attorney for the administrator or personal representative in the action for wrongful act, neglect or default who receives payment shall continue to serve as attorney until entry of a final decree in the Court; and it is further that the filing of a bond is dispensed with; and it is further ORDERED that all other restrictions shall remain in full force and effect. SURROGATE American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS Proceeding to Lift Restrictions to Collect the Proceeds of a WrongfuJ Death Proceeding by as the Administrator of the Estate of Deceased Notice is Hereby Given That: Notice of Application File No. 1) An application to Lift the Restrictions to CoJlect the Proceeds of a Wrongful Death Proceeding of the estate of the above named decedent, has been made by Administrator, whose post office address is 2) Administrator prays that the Decree be modified for the Collection of the Proceeds of a Wrongful Death to 3) The names and post office addreSses of each and every distributee of the above named decedent as set forth in the petition and known to the undersigned as follows: Name of Distributee Domicile and Post Office Address (Continue on reverse if more space is needed) Signature of Petitioner or Attorney Name and Address of Attorney Phone No. American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS Proceeding to Lift Restrictions to Collect the Proceeds of a Wrongful Death Proceeding by as the Administrator of the Estate of Decea$ed State Of New York County Of Affidavit of Mailing File No. --------------../residing at being duly sworn, deposes and says that deponent is over the age of eighteen years; that on 20, deponent mailed a copy of the foregoing Notice of contained in a securely closed postpaid wrapper, directed to each of the person named in paragraph 3 above respectively, as follows: by depositing the document in a Jetter box or other official depository under the exclusive care and custody of the United States Post Office, located at: Sworn to before me this dayof 20 Notary Public Commission Expires: (Affix Stamp or Seal) Signature --- American LegalNet, Inc. www.FormsWorkFlow.com CHECKLIST PROCEEDING TO LIFT RESTRICTIONS AFTER SETTLEMENT OF WRONGFUL DEA TH ACTION REQUIRED ITEMS: l. PETITION TO LIFT RESTRICTIONS 2. PROPOSED ORDER 3. COPY OF STIPULATION OF SETTLEMENT 4. NOTICE OF APPLICATION TO ALL INTERESTED PARTIES 5. PAJD FUNERAL BILL 6. COPY OF RETAINER AGREEMENT 7. ITEMIZED LIST OF DISBURSEMENTS 8. $45.00 FILING FEE American LegalNet, Inc. www.FormsWorkFlow.com