Wrongful Death Compromise Settlement Proceeding Checklist (see Surrogates Court Form WD-2, rev. 4/98) (see 22 NYCRR Uniform Rule 207.38) Fill in All Areas On All Pages - Also Mark When Not Applicable When Necessary Strike Any Paragraphs/Sections Which Do Not Apply Check All Forms To Make Sure Venue Is Correct - Appropriate County Is Listed PET # DESCRIPTION YES NO Does this Surrogates Court have jurisdiction over the proceeding? NOTE: If an action has been commenced in Supreme Court - proof of disposition of the matter must be provided: withdrawal, discontinuance, Supreme Court order transferring action/part of action, etc. Does the caption mirror the estate file name and appointee. 1. Is the petitioner a proper party? [see EPTL 5-4.6(a)] Is the petitioner ... the appointed fiduciary a personal representative 2. Is the decedents residence and persons resided with listed? 3. Is the date letters of guardianship were issued for any infant children listed? Are the names of the infant children listed as well as the name of the Court where the guardianship issued? Is a copy of the letters of guardianship attached? NOTE: A guardian must be appointed for any child receiving funds in excess of $10,000.[see SCPA 2220(1)] 4. Is the date Limited Letters were issued, the decedents name and mention of bond status listed? 5. Is the occupation of the decedent listed? Are the place of employment and address of employment listed? Are the weekly earnings of the decedent listed? 6. Are the age of the decedent and date of birth listed? 7. Are the date and time of the injuries which caused the decedents death listed? Is the location of the place of injury listed? NOTE: If the cause of action did not arise under New York law, the laws of the jurisdiction under which the cause of action arose must be established to the satisfaction of the Court. WDCS-CHK release 7/14/03 PAGE 1 >>>> 2 PET # DESCRIPTION YES NO Has the fatal incident been described? 8. Is the name of the hospital listed? Is the date, time of death and hospital stay detailed? Are all the proceeds of the action to be allocated to wrongful death? Is there an allocation for conscious pain and suffering? NOTE: If any of the compromise settlement is to be attributed to conscious pain and suffering the court will require a full description of the injury/incident to include but not limited to: police reports, hospital records, affidavits, pleadings, discovery/investigation documents, etc. 9. Are all defendents, court location, title, and type of any other action commenced listed? Is the name of the insurance company listed? Is the amount of the settlement listed? Is the maximum insurance policy coverage listed? 10. Has a complete listing of the assets of the defendant(s) been provided? 11. This paragraph states that the settlement being compromised is the largest obtainable amount. 12. Are the petitioners reasons for acceptance of the settlement listed? 13. Are the names of all survivors listed? Are the relationships of all survivors indicated? Are the dates of birth of all survivors listed? Are the present ages of all survivors indicated? 14. Is the date the petitioner retained counsel indicated? Is a copy of the retainer agreement attached? Affidavit of services must be attached (unless attorneys fees were previously approved by another court transferring action). Are the proper amounts listed for:Attorneys disbursements? Attorneys fees? Additional disbursements? 15. Are the following statistics indicated? Decedents age and date of birth WDCS-CHK release 7/14/03 PAGE 2 >>>> 3 PET # DESCRIPTION YES NO Decedents date of death and life expectancy Petitioners date of birth and life expectancy 15. All distributees names, age as of decedents date of death, anticipated cont. years of dependency and percent of net amount of settlement (Kaiser formula may apply) If a structured settlement, set forth cost of any annuity If parents are sole distributees and distribution is unequal, give reasons NOTE: Where recovery or part thereof is allocated to conscious pain and suffering, the proceeds pass through the decedents estate either in accordance with the provisions of the will, or in the event of intestacy, in accordance with EPTL 4-1.1. 16. Are all infant distributees listed? 17. This paragraph states that petitioner waives statutory commissions and filing of a surety bond. 18. Is cost of decedents funeral bill listed? Is copy of paid bill attached? Are any hospital/medical bills listed as outstanding? 18a. Are the facts of any social services claim detailed? 18b. Are the facts of any creditors claims detailed? 18c. If a pecuniary loss by a parent is being sought, has that been indicated? 19. Is information as to decedent receiving public assistance in form of Aid to Dependent Children provided? 20. Has any previous application been made for same type of relief? 21. Has the name of the insurance company and the claim holder been listed? Has a request been made by the fiduciary to close the estate? 22. Are the names, relationships, and addresses of all interested parties listed? NOTE: Interested parties may include but are not limited to - Husband, Wife, Administrator or Administratrix, Executor or Executrix, Daughter, Son, Father, Mother, Alleged Creditor, Department of Social Services, New York State Tax Commission, Insurance Company, Additional Defendants. Are all persons under disability and/or infants under the age of fourteen indicated? A complete statement of the nature and extent of the disability other than infancy of distributees must be attached. WDCS-CHK release 7/14/03 PAGE 3 >>>> 4 PET # DESCRIPTION YES NO NOTE: A guardian ad litem may be appointed for any person listed in the petition as a person under disability. If the person under disability appears by a guardian of the property, committee, conservator or guaridan of the property pursuant to Article 81 of the Mental Hygiene Law whom the Court finds has no adverse interest, no guardian ad litem is necessary. 23. Are all persons/agencies required to be cited indicated with name and address? 23. Under WHEREFORE Clause: has all relief requested been checked and cont. completed? Has any relief not applicable been struck out? Is petition dated, signed, verified, properly notarized (including proper jurat and expiration date of notarys commission)? Is attorneys name, address and phone number listed? Has Part 130 Certif