MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO ESTATE OF ___________________________________________________________, DECEASED CASE NO. ______________________ REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry filed_____________________________,_________, the proceeds have been paid as 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:________________________________ $____________________ To:________________________________ $____________________ Total payments to beneficiaries $____________________ Balance $_____________________ 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 Attorney Registration No.________________ _________________________________ Fiduciary FORM 14.3-REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS American LegalNet, Inc. www.FormsWorkFlow.com [Side 2 of Form 14.3] ENTRY The above report of the distribution of the proceeds is hereby approved. There being no further assets to administer, the fiduciary and surety, if any, are discharged. __________________________________ Date ______________________________________ Probate Judge FORM 14.3-REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS American LegalNet, Inc. www.FormsWorkFlow.com