Report Of Distribution Of Wrongful Death And Survival Claims
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Report Of Distribution Of Wrongful Death And Survival Claims Form. This is a Ohio form and can be use in Lorain County (Court Of Common Pleas).
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Tags: Report Of Distribution Of Wrongful Death And Survival Claims, 14.3, Ohio County (Court Of Common Pleas), Lorain
LORAIN COUNTY PROBATE COURT
JUDGE JAMES T. WALTHER
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: ________________________________
$ _________________________
$ _______________________________
Total payments to beneficiaries
Balance
-0-
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
_________________________________
Fiduciary
Attorney Registration No. ____________________
FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS
4/1/97
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(Reverse 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
_____________________________________
JUDGE
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