MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO ESTATE OF ___________________________________________________________, DECEASED CASE NO. ______________________ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, 2125.03, 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 the case number being_______________________________________________. A judgment has been recovered for damages for decedent's wrongful death (and personal injury and property damage arising out of the same act and which survive the decedent). The amount of the settlement or judgment is $___________________________________. This 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's services is $__________________ and an itemization of such services is attached. A reasonable attorney fee for the attorney's services is $____________________________ and reimbursement to the attorney for case expenses is $_____________________. A copy of the attorney's fee contract that (has) or (has not) received prior approval of this Court, subject to modification, and an itemization of case expenses are attached. The net proceeds of $__________________ should be allocated. $__________________to be wrongful death action and $_______________ to the survival action. A statement in support thereof is attached. 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 are to be distributed. The beneficiaries of the wrongful death action are not an 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. FORM 14.0-APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS American LegalNet, Inc. www.FormsWorkFlow.com The surviving spouse, children, and parents of the decedent and the other next of kin who have suffered 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 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.________________ ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets____________________________at__________o'clock____.M. as the date and time for the hearing the above application and orders notice to be given by the fiduciary, as provided in the Rules of Civil Procedure, to the wrongful death and survival claim beneficiaries who have not waived. __________________________________ Probate Judge FORM 14.0-APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS ________________________________ Fiduciary American LegalNet, Inc. www.FormsWorkFlow.com