PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE PROPOSAL FOR WRONGFUL DEATH SETTLEMENT CASE NO. _______________________ Decedent's Name: Fiduciary's Name: Attorney's Name (Plaintiff): Attorney's Name (Tortfeasor): Is settlement final as to all defendants? Was Suit filed? Nature of Claims: Court: Case #: Age Expenses Offer of Settlement Structured? Present Value Best rating of annuity underwriter $ $ Last Illness Funeral Expenses Attorney Fee ( Attorney Expenses Net for Distribution Consensual Distribution Name Relationship Age Amount $ $ $ $ $ (Total from Continuation of Consensual Distribution $ __________) Date [Details of Structure on Reverse Side] Total Distributed $ $ $ (%)$ $ $ Conscious Pain Suffering $ Judge Jack R. Puffenberger «QXET2J- PAGE 1 OF FORM PWDS1 ­ PROPOSAL FOR WRONGFUL DEATH SETTLEMENT American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _______________________ Continuation of Consensual Distribution Name Relationship Age Amount $ $ $ $ $ Total of Continuation of Consensual Distribution $ Details of Structure PAGE 2 OF FORM PWDS1 ­ PROPOSAL FOR WRONGFUL DEATH SETTLEMENT American LegalNet, Inc. www.FormsWorkFlow.com