PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE ESTATE OF______________________________________________________, DECEASED CASE NO._________________________ ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Upon hearing the application to approve settlement and distri bution of the wrongful death and survival claims, the Court: Approves the proffered settlement of $ _____________________________. Orders payment of $ _____________________ to be applied to decedent's funeral and burial expenses. Orders payment of $ _________________________ to the fiduciary for services rendered with re spect to the wrongful death and survival claims. Orders payment of $_________________________ to th attorney for reimbursement of case expenses and $ e _____________________________ 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 surv claim. The amount allocate to ival d the survival claim shall be considered an asset of the esta and shall be reflected in the fiduciary's account of te the administration of the estate. Finds all of the beneficiaries of the wrongful deat claim are on an equal degree of consanguinity, are adults, h and have agreed how the net proceeds allocated to the wrongful death claim are to be distributed. Orders distribution of the net proceeds alocated to the wrongful death claim to the surviving spouse, children, l parents and other next of kin, in the equitable shares shown below, fixed by the Court having due regard for the injury and loss to each beneficiary resulting from the death and for the age and condition of the beneficiaries. __________________________________________________________________________ ____________________________________________________________________________________________ Name Residence Relationship Birthdate Amount Address to Decedent of Minor ___________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Page 1 of 2 FORM 14.2 ­ ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 09/01/11 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _________________ Orders that the share of: ________________________________________________________________ a minor(s) be deposited pursuant to 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 attorneyto report the distribution of the proceeds within thirty days of the date of this Entry . Further orders ________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Approved: _________________________________________ Attorney for Fiduciary _______________________________________________ Ralph Winkler, Probate Judge Attorney Registration No. ____________________ ______________________________________________ Date Page 2 of 2 FORM 14.2 ­ ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS American LegalNet, Inc. www.FormsWorkFlow.com