PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE ESTATE OF CASE NO. , DECEASED APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, Civ. R. 19.1 and Sup. R. 70] The fiduciary states: [Check whichever of the following are applicable, strike inapplicable words, and incorporate all attachments into a single statement.] There is an offer of (full) (partial) settlement without suit being filed. There is an offer of (full) (partial) settlement after suit was filed. The style of the case, the court, and case number being _. A judgment has been recovered for damages for the decedent's wrongful death (and personal injury and property damage arising out of the same act and which survive the decedent). The amount of the settlement or judgment is $_ . There is a partial settlement and therefore the estate must remain open pending final disposition of the claims. The offer includes, or the judgment sets forth separately, reasonable funeral and burial expenses in the amount of $_ _. Reasonable compensation for the fiduciary for services rendered is $_ an itemization of such services is attached. Outstanding hospital and medical bills in the amount of $_ itemization of such bills is attached. and an and Outstanding claims to a right of subrogation for the payment of hospital and medical bills in the amount of and an itemization of such is attached. $_ A reasonable attorney fee for the attorney's services is $_ and reimbursement to the attorney for case expenses is $ . A copy of the attorney's fee contract that (has) (has not) received prior approval of the Court, subject to modification, and itemization of the case expenses are attached. Other: _. should be allocated $ to the wrongful to the survival action. A statement in support thereof is attached. The net proceeds of $_ death action and $_ FORM 14.0 ­ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Amended: January 1, 2015 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 14.0] CASE NO. A statement in support of the proffered settlement is attached. Supplemental forms required by local rule of court are attached. All of the beneficiaries of the wrongful death action are on equal degree of consanguinity, are adults, and have agreed how the net proceeds allocated to the wrongful death claim are to be distributed. The beneficiaries of the wrongful death action are not all on equal degree of consanguinity, or one or more of the beneficiaries is a minor, or the beneficiaries have not agreed how the net proceeds are to be distributed. The surviving spouse, children, and parents of the decedent and the other next of kin who have suffered damages by reason of the wrongful death are as follows and the distribution should be as follows: Name Residence Address Relationship to Decedent Birthdate of Minor Amount The survival claim beneficiaries are as follows: Name Residence Address Relationship to Decedent Birthdate of Minor Amount The fiduciary requests that the Court approve the application and authorize the fiduciary to execute a (complete) (partial) release which upon payment of the settlement shall be a (complete) (partial) discharge of the claim. Attorney for Fiduciary Attorney Registration No. Fiduciary ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets at o'clock _.m. as the date and time for hearing the above application and orders notice to be given by the fiduciary, as provided in the Rules of Civil Procedure, to the wrongful death and survival claim beneficiaries who have not waived notice. Alice O. McCollum, Probate Judge FORM 14.0 ­ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Amended: January 1, 2015 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com