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 Probate Judge Attorney Registration No. ____________________________ __________________________________________ Date American LegalNet, Inc. www.FormsWorkflow.com