COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.ERIEPROBATE COURT OF COUNTY, OHIOCalendar No.IN THE MATTER OF THE WRONGFUL DEATH OFDECEASED Case No., JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)DocketPageJOURNAL ENTRY AND FORMAL DECLARATION OF WRONGFUL DEATH TRUST FOR MINOR CHILDREN BENEFICIARIESThe Grantor, the Probate Judge, hereby creates an irrevocable Trust pursuant to the Ohio Revised Code § 2125.03, for the purposes and upon the terms and provisions contained in the Wrongful Death Trust Agreement for Minor Beneficiaries as officially recorded with the Ohio Supreme Court as Standard Probate Form No. pursuant to Rule 16 of the Rules of Superintendence for Courts of Common Pleas. Said Wrongful Death Trust is hereby incorporated in this Formal Declaration by reference, the same as if fully rewritten herein.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2125.03Rule 16THE PEOPLE OF THE STATE OF NEW YORK TOThis Trust is created for the benefit of the decedent's children,. Simultaneous with the execution of this Formal Declaration, the Court hereby orders the allocation toGREETINGS:minor children as set forth in the order of distribution in the estate of in the Probate Court of County, Case No. , which represents the lump sum payment of $ be transferred to the Trustee of the Trust herein created.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableERIE,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomThe Court hereby appoints as Trustee of this Trust. This Trust shall in all respects be treated as a testamentary Trust by the Probate Court, requiring annual accountings and following such other orders as the Court may from time to time issue. IN WITNESS WHEREOF, the parties hereto have executed this Formal Declaration of Trust, the Trustee hereby accepting the duties and liabilities as Trustee and shall be effective as of the date of filing with the Probate Court.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Judge, one of the Justices of theCourt in Witness, Honorableday of, 20 County,of the County Probate Court, Grantor(Attorney must sign above and type name below)TrusteeAttorney(s) forCONSENT TO APPOINTMENT OF TRUSTEEPursuant to Ohio Revised Code § 2125.03, the undersigned hereby consents to the appointment of the Trustee designated in the Formal Declaration of Trust and executes this Consent on the day of .Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Guardian of Minor Child(ren) BeneficiariesMobile Tel. No.:FORM 14.2C JOURNAL ENTRY AND FORMAL DELARATION OF WRONGFUL DEATH TRUST FOR MINOR CHILDREN BENEFICIARIES (6/90)American LegalNet, Inc. www.USCourtForms.com