PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge ESTATE OF ________________________________________________________, DECEASED CASE NUMBER ______________________________________ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, 2125.03, Civ. R. 19.1 and Sup. R. 70] The fiduciary states: [Check whichever of the following are applicable, strike inapplicable words, and incorporate all attachments into a single statement.] 9 9 9 There is an offer of (full)(partial) settlement without suit being filed. There is an offer of (full)(partial) settlement after suit was filed. The style of the case, the Court, and the case number is _______________________________________________________________________ . A judgement has been recovered for damages for decedent’s wrongful death (and personal injury and property damage arising out of the same act and which survive the decedent). 9 The amount of the settlement or judgement is $ ____________________________________ . 9 This is a partial settlement and therefore the estate must remain open pending final disposition of the claims. 9 9 9 9 9 9 9 9 The offer includes, or the judgement sets forth separately, reasonable funeral and burial expenses in the amount of $ _________________________________________. Reasonable compensation for the fiduciary’s service is $ _____________________________ and an itemization of such services is attached. A reasonable attorney fee for the attorney’s services is $ _____________________________ and reimbursement to the attorney for case expenses is $ ____________________________. A copy of the attorney’s fee contract that (has) (has not) received prior approval of this Court, subject to modification, and an itemization of case expenses are attached. The net proceeds of $ ____________________ should be allocated $_____________________ to the wrongful death action and $__________________________ to the survival action. A statement in support thereof is attached. A statement of the proffered settlement is attached. Supplemental forms required by local rule of Court are attached. All of the beneficiaries of the wrongful death action are on an equal degree of consanguinity, are adults, and have agreed how the net proceeds are to be distributed. All of the beneficiaries of the wrongful death action are on not on an equal degree of consanguinity, or one or more of the beneficiaries is a minor, or the beneficiaries have not agreed how the net proceeds are to be distributed. Form 14.0 APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com 9 The surviving spouse, children, and parents of the decedent and other next of kin who have suffered damages by reason of the wrongful death are as follows and the distribution should be as follows: __________________________________________________________________________________________________ Name Residence Address Relationship to Decedent Birthdate of Minor Amount __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 9 The survival claim beneficiaries are as follows: _________________________________________________________________________________________________ Name Residence Address Relationship to Decedent Birthdate of Minor Amount _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ The fiduciary requests that the Court approve the application and authorize the fiduciary to execute a (complete)(partial) release which upon payment of the settlement shall be a (complete)(partial) discharge of the claim. ____________________________________________ ________________________________________ Attorney for Fiduciary Fiduciary Attorney Registration No. ____________________________ ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets __________________________ at _____________ o’clock ____ . M. as the date and time for hearing the above application and orders notice to be given by the fiduciary, as provided in the Rules of Civil Procedure, to the wrongful death and survival claim beneficiaries who have not waived notice. _______________________________________ Probate Judge American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge ESTATE OF ________________________________________________________, DECEASED CASE NUMBER ______________________________________ WAIVER AND CONSENT WRONGFUL DEATH AND SURVIVAL CLAIMS The undersigned waive notice of the hearing and consent to and approve the settlement and distribution as set forth in Form 14.0 (Application to Approve Settlement and Distribution of Wrongful Death and Survival Claims) a copy of which I have received ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ Form 14.1 - Waiver and Consent Wrongful Death and Survival Claims 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge ESTATE OF ________________________________________________________, DECEASED CASE NUMBER ______________________________________ ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Upon hearing the application to approve settlement and distribution of the wrongful death and survival claims, the Court: 9 Approves the proffered settlement of $ _________________________________. 9 Orders payment of $ ________________________________ to be applied to decedent’s funeral and burial expenses. 9 9 9 9 9 Orders payment of $ ________________________________ to the fiduciary for services rendered with respect to the wrongful 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 the survival claim shall be considered an asset of the estate and shall be reflected in the fiduciary’s account of the administration of the estate Finds all of the beneficiaries of the wrongful death claim are on an equal degree of consanguinity, are adults, and have agreed how 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 and other next of kin, in the equitable shares shown below, fixed by the Court having due regard for the injury and loss of each beneficiary resulting from the death and for the age and condition of the beneficiaries. __________________________________________________________________________________________________ Name Residence Address Relationship to Decedent Birthdate of Minor Amount __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Form 14.2 Entry Approving Settlement and Distribution of Wrongful Death and Survival Claims 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com Orders that the share of : 9 9 9 ____________________________________________________ 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 such minor. ____________________________________________________ a child(ren) be deposited in a trust for the benefit of 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 Fiduciary Probate Judge Attorney Registration No. __________________________ ________________________________________ Date American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge ESTATE OF ________________________________________________________, DECEASED CASE NUMBER ______________________________________ REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry Filed _______________________________________, _________________, the proceeds have been paid as shown below and on the accompanying vouchers. Gross Proceeds $ _____________________ Funeral and burial expenses $ _____________________ Fiduciary fees to ________________________ $ _____________________ Reimbursement of case expenses to ______________________________________ $ _____________________ Attorney fees to _________________________ $ _____________________ Survival claim to the estate $ _____________________ Total deduction $ _____________________ Net proceeds $ _____________________ Net proceeds to Beneficiaries: To: __________________________________ $ _____________________ To: __________________________________ $ _____________________ To: __________________________________ $ _____________________ To: __________________________________ $ _____________________ To: __________________________________ $ _____________________ To: __________________________________ $ _____________________ To: __________________________________ $ _____________________ Total payments to beneficiaries $ _____________________ -0- Balance 9 9 The fiduciary states that there are no other assets remaining in the estate. The fiduciary states that there are assets remaining in the estate. _________________________________________________ Attorney for Fiduciary _____________________________________ Fiduciary Attorney Registration No. ____________________________ Form 14.3 Report of Distribution of Wrongful Death and Survival Claims 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com ENTRY The above report of the distribution of the proceeds is hereby approved. 9 There being no further assets to administer, the fiduciary and surety, if any, are discharged. ____________________________________ Date __________________________________________ Probate Judge American LegalNet, Inc. www.FormsWorkflow.com