PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE ESTATE OF___________________________________________________, DECEASED CASE NO.:__________________ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, 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.] 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 case number being _______________________________________. A judgment has been recovered for damages for the decedent's wrongful death (and personal injury and property damage arising out of the same act and which survive the decendent.) The amount of the settlement or judgment is $_______________________________________. There is a partial settlement and therefore the estate must remain open pending final disposition of the claims. The offer includes, or the judgment sets forth separately, reasonable funeral and burial expenses in the amount of $___________________________. Reasonable compensation for the fiduciary for services rendered is $_____________________ and an itemization of such services is attached. Outstanding hospital and medical bills in the amount of $_______________________and an itemization of such bills is attached. Outstanding claims to a right of subrogation for the payment of hospital and medical bills in the amount of $ ____________and an itemization of such is attached. A reasonable attorney fee for the attorney's services is $______________________________and reimbursement to the attorney for case expanse is $________________________. A copy of the attorney's fee contract that (has)(has not) received prior approval of the Court, subject to modification, and itemization of the case expenses are attached. Other:________________________________________________________________________________________ ___________________________________________________________________. The net proceeds of $___________________ should be allocated $_____________________ to the wrongful death action and $______________ to the survival action. A statement in support thereof is attached. FORM 14.0 ­ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 1/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 14.0] CASE NO._________________ A statement in support 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 equal degree of consanguinity, are adults, and have agreed how the net proceeds allocated to the wrongful death claim are to be distributed. The beneficiaries of the wrongful death action are not all on 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. The surviving spouse, children, and parents of the decedent and the 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 Relationship Birthdate Amount Address to Decedent of Minor _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ The survival claim beneficiaries are as follows: _____________________________________________________________________________________________ Name Residence Relationship Birthdate Amount Address to Decedent of Minor _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 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 Attorney Registration No._________________ ______________________________________ Fiduciary FORM 14.0 ­ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 1/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com