MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF _____________________________________________________________ CASE NO. _____________________ REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM Pursuant to Entry filed_______________________, ____, the proceeds have been paid as shown below and on the accompanying vouchers. Gross Proceeds Less: Medical expenses Reimbursement of suit expenses to ____________ _________________________________________ Attorney fees to ____________________________ Loss of service to ___________________________ Other: ____________________________________ Total Net Proceeds Deposited pursuant to R.C. 2109.13 Form 22.3 attached Delivered to __________________________________, legal guardian of the estate Delivered to __________________________________, parent_ and natural guardian_ Delivered to __________________________________, the person by whom the minor is maintained Structured ­ see documents previously filed Balance ________________________ Attorney for Applicant Attorney Registration No. ____________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ 0.00 $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ 0.00 $_______________ _______________________ Applicant ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. ________________________ _______________________ Date Probate Judge FORM 22.4 ­ REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM Print Reset American LegalNet, Inc. www.FormsWorkFlow.com