PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE ESTATE OF CASE NO. , DECEASED REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry filed shown below and on the accompanying vouchers. Gross proceeds Funeral and burial expenses Fiduciary fees to Reimbursement of case expenses to $ Attorney fees to Survival claim to the estate Total deductions Net proceeds Net proceeds to beneficiaries. To: To: To: To: To: To: To: Total payments to beneficiaries Balance $ $ $ $ $ $ $ $ -0$ $ $ $ $ $ $ , , the proceeds have been paid as The fiduciary states that there are no other assets remaining in the estate. The fiduciary states that there are assets remaining in the estate. Attorney for Fiduciary Fiduciary Attorney Registration No. H.C. FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 04/01/97 American LegalNet, Inc. www.FormsWorkFlow.com