FORM 14.0 APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS AMENDED: January 1, 2015 Discard all previous versions of the form PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge ESTATE OF , DECEASED CASE NO. APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS American LegalNet, Inc. www.FormsWorkFlow.com FORM 14.0 APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS AMENDED: January 1, 2015 Discard all previous versions of the form CASE NO. Name Residence Relationship Birthdate Amount Address to Decedent of Minor Name Residence Relationship Birthdate Amount Address to Decedent of Minor ENTRY SETTING HEARING AND ORDERING NOTICE , PROBATE JUDGE American LegalNet, Inc. www.FormsWorkFlow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIOAnthony J. Russo, Presiding JudgeLaura J. Gallagher, JudgeESTATE OF , DECEASEDCASE NUMBER WAIVER AND CONSENT WRONGFUL DEATH AND SURVIVAL CLAIMSThe undersigned waive notice of the hearing and consent to and approve the settlement and distribution as set forth in Form14.0 (Application to Approve Settlement and Distribution of Wrongful Death and Survival Claims) a copy of which I havereceivedForm 14.1 - Waiver and Consent Wrongful Death and Survival Claims 10/1/98 American LegalNet, Inc. www.FormsWorkFlow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIOAnthony J. Russo, Presiding JudgeLaura J. Gallagher, JudgeESTATE OF , DECEASEDCASE NUMBER ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OFWRONGFUL DEATH AND SURVIVAL CLAIMSUpon hearing the application to approve settlement and distribution of the wrongful death and survival claims, the Court: Approves the proffered settlement of $ . Orders payment of $ to be applied to decedent222s funeral and burial expenses. Orders payment of $ to the fiduciary for services rendered with respect to thewrongful death and survival claims. Orders payment of $ to the attorney for reimbursement of case expenses and $ for attorney fees for services rendered with respect to the wrongful death and survival claims. Orders that the net proceeds of $ be allocated $ to the wrongful death claim and $ to the survival claim. The amount allocated to thesurvival claim shall be considered an asset of the estate and shall be reflected in the fiduciary222s account of the administrationof the estate Finds all of the beneficiaries of the wrongful death claim are on an equal degree of consanguinity, are adults, and have agreedhow the net proceeds allocated to the wrongful death claim are to be distributed. Orders distribution of the net proceeds allocated to the wrongful death claim to the surviving spouse, children, parents andother next of kin, in the equitable shares shown below, fixed by the Court having due regard for the injury and loss of eachbeneficiary resulting from the death and for the age and condition of the beneficiaries.NameResidenceRelationshipBirthdateAmountAddressto Decedentof MinorForm 14.2 Entry Approving Settlement and Distribution of Wrongful Death and Survival Claims10/1/98 American LegalNet, Inc. www.FormsWorkFlow.com Orders that the share of : a minor(s) be deposited in lieu of bond pursuant of R.C.2111.05. a minor(s) be paid to the guardian of the estate of suchminor. a child(ren) be deposited in a trust for the benefitof the child(ren) until twenty-five years of age.Authorizes the fiduciary to execute a release which, upon payment, shall be a discharge of the claim.Orders the fiduciary and the attorney to report the distribution of the proceeds within thirty days of the date of this Entry.Further orders Approved:Attorney for FiduciaryProbate JudgeAttorney Registration No. Date American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com