LORAIN COUNTY PROBATE COURT JUDGE JAMES T. WALTHER IN THE MATTER OF ______________________________________________ CASE NO. _______________ ENTRY APPROVING SETTLEMENT OF A MINOR'S CLAIM Upon hearing the application to approve and distribute the settlement of the claim of the minor, the Court: [check whichever of the following are applicable] Approves the proffered settlement of $________________________ ; Orders payment of $ _______________________ for medical and other expenses, as follows: ___________________________________________________________________________________ ___________________________________________________________________________________ Orders payment of $ _______________________ to the attorney for reimbursement of suit expenses and $ _____________________ for attorney fees for service rendered with respect to this matter; Orders payment of $ ______________________ to the parent _______________________ , for damages on account of loss of service of this minor; Authorizes the applicant to execute a release which shall be effective upon payment of the settlement; Orders that the net amount of $ _______________________ , for the benefit of the minor be: Deposited in the name of the minor and not to be released until the minor attains the age of majority or upon further order of this Court with Form 22.3 Verification of Receipt and Deposit filed with the Court; Delivered to the legal guardian of the estate of this minor; Delivered to ________________________________________, parent and natural guardian; Delivered to ________________________________________, the person by whom the minor is maintained; Structured as set forth in the documents attached to the application; Orders the applicant and the attorney to report on their distribution of the proceeds within thirty days of the date of this entry; Further orders Attorney for the minor shall be responsible for the deposit of funds and return the RECEIPT OF DEPOSIT form to the Court within 14 days. ______________________________________ Date __________________________________ Judge FORM 22.2 - ENTRY APPROVING SETTLEMENT OF A MINOR'S CLAIM 10/1/98 American LegalNet, Inc. www.FormsWorkFlow.com