For Office Use Only Filing Fee Paid $ Receipt No.: DO NOT LEA VE ANY ITEMS BLANK SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS PROCEEDING BY----------255 AS ADMINISTRATOR OF THE ESTATE OF Deceased, TO LIFT RESTRICTIONS. ------------------------------------------------------------------X TO THE SURROGATE'S COURT, COUNTY OF QUEENS: PETITION TO LIFT RESTRICTIONS (Structured Settlement) File No .. The petition of , Administrator of the Estate of ------------267 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 pending in the Supreme Court, County, under Index No. was settled in the form of a structured settlement with a cost of$ (consisting of$ in up-front cash and future periodic payments at a cost 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) that the sum of$ from the settlement be paid by defendant, --------- payable to-----------' the structured settlement annuity assignee or life insurer issuing the structured settlement annuity, be delivered to -------------the structured settlement annuity broker placing this case to fund the purchase of a structured settlement annuity or annuities and to lock-in the benefits presented and/or interest rate, subject to review and approval by this Court as part of the proceeding to compromise the action and to judicially settle the account; (3) that the balance of the settlement funds, after deducting attorney's fees and disbursements and the cost of a structured settlement annuity or annuities, be deposited in an interest bearing escrow account for the benefit of the decedent's estate and distributees; (4) that attorneys fees in the sum of and reimbursement of disbursements in the sum of , for a total of be fixed and approved; (5) that the attorney for the administrator or personal representative be directed to continue to serve -2- American LegalNet, Inc. www.FormsWorkFlow.com as the attorney for said administrator or personal representative until the entry of a Final Decree in the proceeding to compromise the action and judicially settle the account in this Court without further compensation; (6) 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; (7) All other restrictions shall remain in effect. Dated:----------- Petitioner's Name (Printed) Petitioner's Signature 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. Petitioner's Signature State of New York) )ss.: County of Queens ) 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 (To Lift Restrictions255Structured Settlement) 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 sum of$ be paid by defendant, payable to (fill in assignment company or life insurance company) , and delivered to the structured settlement annuity broker placing this case to fund the purchase of a structured settlement annuity or annuities and to lock-in the benefits presented and/or interest rate, subject to review and approval by this Court as part of the proceeding to compromise the action and to judicially settle the account; and it is further ORDERED that the balance of the settlement funds, after deducting attorneys fees and disbursements and the cost of a structured settlement annuity or annuities, be paid to the firm of ----------------' petitioner's attorneys, and shall be deposited in an interest bearing escrow account for the benefit of the decedent's estate and distributees; and it is further ORDERED that the attorney for the administrator or personal representative is directed to continue to serve as the attorney for the administrator or personal representative until the entry of a Final Decree in the proceeding to compromise the action and judicially settle the account in this Court without further compensation; and it is further ORDERED that the restrictions as listed in the Limited Letters of Administration are modified to permit the settlement and payment by defendant, , to plaintiff's counsel of the up-front cash portion of the settlement in the sum of $ , which is inclusive of attorney's fees and disbursements, and to , the structured settlement assignee or life insurance company annuity issuer for purchase of a structured settlement annuity or annuities, at a cost in the sum of$ and it is further ORDERED that as administrator or personal representative of the Estate of , shall provide defendant with a General Release which recites the amount of up-front cash and the amount of annuity funding, all of which shall be payable forthwith, including payment to the life insurers and/or assignment companies; and it is further ORDERED that the administrator or personal representative and the defendant or defendant's carrier shall forthwith execute an apprqpriate settlement agreement setting forth the terms of the structured American LegalNet, Inc. www.FormsWorkFlow.com settlement; and it is further ORDERED that the final terms of the structured settlement and all periodic payments including, but not limited to, the amounts, dates of periodic payments, and payees shall remain subject to approval of this Court; and it is further ORDERED that the life insurers issuing the annuities or funding agreements to provide the periodic payments shall not make any payments to the distributees until this Court has issued a final decree approving the allocation and distribution of the settlement; and it is further ORDERED that the defendant and/or defendant's carrier shall forthwith execute qualified assignments consistent with the settlement agreement; and it is further ORDERED that in the event any party to the settlement agreement or qualified assignment is incapable of executing additiona