Probate Court of Cuyahoga County, Ohio John J. Donnelly, Presiding Judge John E. Corrigan, Judge IN THE MATTER OF ___________________________________________________________ CASE NUMBER: ______________________________________ APPLICATION TO SETTLE A MINORS 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 (an d damage to this minors property) by wrongful act, neglect, or default that entitles this minor to maintain a n action to recover damages. A copy of the birthcertificate is attached. Attached is a narrative statement in support of the proffered settlement setting forth a description of the occurrence, theinjury or damage, the treatment progress and current prognosis by the tr eating physicians, and other proposed or actualsettlements resulting from the same occurrence being paid to persons oth er than this minor. Counsel will advise at thehearing as to liability and collectability. 9 There is no legal guardian of the estate, and the Court may authorize th e 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 mai ntained. 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 attorneys services is $ __________ ________________ and reimbursement to the attorney for suit expenses is $ ________________________ . A copy o f the attorneys fee contract that has (has not) received prior approval of this Court. Subject to modificati on, and an itemization of suit expenses are attached. form 22.0 - Application to settle a minors claim and entry setting hear ing. 10/1/98 American LegalNet, Inc. www.USCourtForms.com>>>> 2 9 The parent __ , _____________________________ , claim $ ________________ _______ for damages on account of loss of services of this minor and that claim is included in this settle ment offer. 9 This is a structured settlement. All necessary documents including a st atement of the present value of the settlement, are filed herewith. The applicant requests that: 9 The Court authorizes the applicant to execute a release which shall be e ffective upon payment of the settlement 9 the Court order payment of the above expenses and order that the net amo unt of $ _____________________ to the benefit of the minor be: 9 Deposited in the name of the minor with ______________________ 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 gua rdian ____ . 9 Delivered to ________________________________ , the person by whom the m inor 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 Applicant ___________________________________________ ___________________________________________ Typed or Printed Name Typed or Printed Name ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Address Address ___________________________________________ ___________________________________________ Phone Number (include Area code) Phone Number (include area code) ___________________________________________ Attorney Registration No. ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets ___________________________________ , at ______ ocloc k __. __m. as the date and time for hearing theabove application and orders notice to be given by the applicant, as pro vided in the Rules of Civil Procedure, to the parents whohave not waived notice and (further orders that the minor and parent __ ___ attend the hearing.) ___________________________________________ Probate Judge American LegalNet, Inc. www.USCourtForms.com