Lorain County Probate Court Judge James T. Walther ESTATE OF _______________________________________________________, DECEASED CASE NO. _______________________ ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Upon hearing the application to approve settlement and distribution of the wrongful death and survival claims, the Court: Approves the proffered settlement of $ _______________________________. Orders payment of $ _____________________________ to be applied to decedent's funeral and burial expenses. Orders payment of $ ____________________________ to the fiduciary for services rendered with respect to the wrongful death and survival claims. Orders payment of $ ____________________________ to the attorney for reimbursement of case expenses and $ ______________________________ for attorney fees for services rendered with respect to the wrongful death and survival claims. Orders that the net proceeds of $ _____________________________ be allocated $ ____________________ to the wrongful death claim and $ ______________________________ to the survival claim. The amount allocated to the survival claim shall be considered an asset of the estate and shall be reflected in the fiduciary's account of the administration of the estate. Finds all of the beneficiaries of the wrongful death claim are on an equal degree of consanguinity, are adults, and have agreed how the net proceeds allocated to the wrongful death claim are to be distributed. Orders distribution of the net proceeds allocated to the wrongful death claim to the surviving spouse, children, parents and other next of kin, in the equitable shares shown below, fixed by the Court having due regard for the injury and loss to each beneficiary resulting from the death and for the age and condition of the beneficiaries. ___________________________________________________________________________________________ Name Residence Relationship Birthdate Amount Address to Decedent of Minor ___ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ FORM 14.2 - ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 4/1/97 American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 14.2) Orders that the share of: ______________________________________________________________________a minor(s) be deposited in lieu of bond pursuant to R.C. 2111.05. ______________________________________________________________________a minor(s) be paid to the guardian of the estate of such minor. _______________________________________________________________________a child(ren) be deposited in a trust for the benefit of the child(ren) until twenty-five years of age. Authorizes the fiduciary to execute a release which, upon payment, shall be a discharge of the claim. Orders the fiduciary and the attorney to report the distribution of the proceeds within thirty days of the date of this Entry. Further orders ______________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Approved: ____________________________________________ Attorney for Fiduciary ______________________________________ JUDGE Attorney Registration No. ____________________ ______________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com