PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge IN THE MATTER OF _______________________________________________________________ CASE NUMBER ______________________________________ APPLICATION TO SETTLE A MINOR’S CLAIM [R.C. 2111.05, R.C. 2111.18, SUP. R. 67 AND 68] [Check applicable boxes, complete applicable blanks, strike inapplicable language, and attach supporting documentation.] The applicant states that: ____________________________________, is an unemancipated minor, born ____________,_______, residing at _______________________________________________ in this county who on or about ______________________, ________, suffered personal injury (and damage to this minor’s property) by wrongful act, neglect, or default that entitles this minor to maintain an action to recover damages. A copy of the birth certificate is attached. Attached is a narrative statement in support of the proffered settlement setting forth a description of the occurrence, the injury or damage, the treatment progress and current prognosis by the treating physicians, and other proposed or actual settlements resulting from the same occurrence being paid to persons other than this minor. Counsel will advise at the hearing as to liability and collectability. 9 There is no legal guardian of the estate, and the Court may authorize the settlement without the appointment of a guardian. 9 _________________________________ is the legal guardian of the estate. Case No. _____________ 9 _________________________________ is (are) the parent __ and natural guardian __. 9 _________________________________ is the person by whom the minor is maintained. 9 There is a (full)(partial) settlement offer of $________________ without suit being filed. 9 There is a (full)(partial) settlement offer of $________________ after suit was filed; the style of the case, court, and case number being ______________________________________________. 9 The proffered settlement should be approved. 9 Unreimbursed medical and other expenses of $________________ have been incurred. Attached is a list of such expenses and proposed payees. 9 A reasonable attorney fee for the attorney’s services is $________________ and reimbursement to the attorney for suit 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 suit expenses are attached. FORM 22.0 - APPLICATION TO SETTLE A MINOR’S CLAIM AND ENTRY SETTING HEARING 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com 9 The parent __, _____________________________, claim $______________________ for damages on account of loss of services of this minor and that claim is included in this settlement offer. 9 This is a structured settlement. All necessary documents including a statement of the present value of the settlement, are filed herewith. The applicant requests that: 9 The Court authorize the applicant to execute a release which shall be effective upon payment of the settlement. 9 The Court order payment of the above expenses and order that the net amount of $________________ for the benefit of the minor be: 9 Deposited in the name of the minor with ____________________________________________, a financial institution, and not to be released until the minor attains the age of majority or upon further order of this Court. 9 Delivered to the legal guardian. 9 Delivered to __________________________________________, parent__ and natural guardian ___ . 9 Delivered to __________________________________________, the person by whom the minor is maintained. 9 Structured as set forth in the attached documents. 9 Supplemental forms required by local rule of court are attached. ________________________________ Attorney for Applicant ________________________________ Typed or Printed Name ________________________________ Address ________________________________ Phone Number (include area code) ________________________________ Applicant ________________________________ Typed or Printed Name ________________________________ Address ________________________________ Phone Number (include area code) 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 applicant, as provided in the Rules of Civil Procedure, to the parents who have not waived notice and (further orders that the minor and parent__ attend the hearing.) _______________________________ Probate Judge American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO JOHN J. DONNELLY, Presiding Judge JOHN E. CORRIGAN, Judge IN THE MATTER OF _______________________________________________________________ CASE NUMBER ______________________________________ WAIVER AND CONSENT TO SETTLE A MINOR'S CLAIM The undersigned waive all claims for damages on account of loss of services of said minor, waive notice of the hearing, and consent to and approve Form 22.0 (Application To Settle A Minor’s Claim) a copy of which is attached hereto. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Typed or Printed Name ___________________________________ Typed or Printed Name ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ FORM 22.1 - WAIVER AND CONSENT TO SETTLE A MINOR'S CLAIM 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO JOHN J. DONNELLY, Presiding Judge JOHN E. CORRIGAN, Judge IN THE MATTER OF _______________________________________________________________ CASE NUMBER ______________________________________ ENTRY APPROVING SETTLEMENT OF A MINOR’S CLAIM Upon hearing the application to approve and distribute the settlement of the claim of the minor, the Court: [check whichever of the following are applicable] 9 Approves the proffered settlement of $______________________; 9 Orders payment of $_________________________________ for medical and other expenses, as follows:________________________________________________________________________ ______________________________________________________________________________; 9 Orders payment of $_______________________ to the attorney for reimbursement of suit expenses and $ ______________________ for attorney fees for service rendered with respect to this matter; 9 Orders payment of $ ____________________________ to the parent __,_____________________, for damages on account of loss of service of this minor; 9 Authorizes the applicant to execute a release which shall be effective upon payment of the settlement; 9 Orders that the net amount of $ _________________________, for the benefit of the minor be: 9 Deposited in the name of the minor and not to be released until the minor attains the age of majority or upon further order of this Court with Form 22.3 (Verification of Receipt and Deposit) filed with the Court; 9 Delivered to the legal guardian of the estate of this minor; 9 Delivered to ______________________________________, parent __ and natural guardian ___; 9 Delivered to ____________________________________, the person by whom the minor is maintained; 9 Structured as set forth in the documents attached to the application; 9 Orders the applicant and the attorney to report on their distribution of the proceeds within thirty days of the date of this entry; 9 Further orders_____________________________________________________________________ _______________________________________________________________________________ ___________________________________ Date ___________________________________ Probate Judge FORM 22.2 - ENTRY APPROVING SETTLEMENT OF A MINOR’S CLAIM 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO JOHN J. DONNELLY, Presiding Judge JOHN E. CORRIGAN, Judge IN THE MATTER OF________________________________________________________________ CASE NUMBER ______________________________________ VERIFICATION OF RECEIPT AND DEPOSIT Pursuant to Court order, the sum of $ ______________________________________ was deposited with _________________________________on the ______ day of _________________________, _______, as evidenced by Savings/Certificate of Deposit Account Number ________________________________. This account is held solely in the name of __________________________________________________, a minor, whose Social Security Number is ____________________________________. By accepting said deposit for said minor, this institution agrees that said deposit, together with accumulated interest, shall be held and no part thereof released until minor attains the age of majority or upon further order of this Court. _________________________________________ Financial Institution By_______________________________________ Authorized Officer _________________________________________ Typed or Printed Name _________________________________________ Phone Number _________________________________________ Date FORM 22.3 - VERIFICATION OF RECEIPT AND DEPOSIT 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO JOHN J. DONNELLY, Presiding Judge JOHN E. CORRIGAN, Judge IN THE MATTER OF _______________________________________________________________ CASE NUMBER ______________________________________ REPORT OF DISTRIBUTION OF A MINOR’S CLAIM Pursuant to Entry filed _______________________, _______, the proceeds have been paid as shown below and on the accompanying vouchers. Gross Proceeds $ _______________ Less: Medical expenses_____________________________ Reimbursement of suit expenses to_______________ ___________________________________________ Attorney fees to______________________________ Loss of service to_____________________________ Other:______________________________________ Total $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Net proceeds 9 Deposited pursuant to R.C. 2109.13 Form 22.3 attached $_______________ legal guardian of the estate $_______________ parent__and natural guardian__ $_______________ the person by whom the minor is maintained $_______________ 9 Delivered to ______________________________, 9 Delivered to ______________________________, 9 Delivered to ______________________________, 9 Structured - see documents previously filed $_______________ Balance $_______0_______ _____________________________________ Attorney for Applicant Attorney Registration No._________________ ________________________________ Applicant ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. _____________________________________ ________________________________ Date Probate Judge FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY OF A MINOR’S CLAIM 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com