MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF ______________________________________________________ CASE NO. ________________________ WAIVER AND CONSENT TO SETTLE MINOR'S CLAIM The undersigned, waive all claims for damages on account of loss of services of said minor, waive notice of the hearing, and consent to approve the Form 22.0, Application To Settle Minor's Claim, a copy of which is attached hereto. __________________________________ __________________________________ Typed or Printed Name __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Type or Printed Name __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Print Reset FORM 22.1 ­ WAIVER AND CONSENT TO SETTLE MINOR'S CLAIM American LegalNet, Inc. www.FormsWorkFlow.com