PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE IN THE MATTER OF: CASE NO.: APPLICATION TO SETTLE A MINOR'S CLAIM [R.C. 2111.05, 2111.18; SUP.R. 67 and 68] [Check applicable boxes, complete applicable blanks, strike inapplicable language and attach supporting documentation.] The applicant states that: is an unemancipated minor, born , in this county who on or about , residing at , , suffered personal injury (and damage to this minor's property) by wrongful act, neglect, or default that entitles this minor to maintain an action to recover damages. A copy of the birth certificate is attached. Attached is a narrative statement in support of the proffered settlement setting forth a description of the occurrence, the injury or damage, the treatment progress and current prognosis by the treating physicians, and other proposed or actual settlements resulting from the same occurrence being paid to persons other than this minor. Counsel will advise at the hearing as to liability and collectability. There is no legal guardian of the estate, and the Court may authorize the settlement without the appointment of a guardian. is the legal guardian of the estate. Case No. is (are) the parent(s) and natural guardian(s). is the person by whom the minor is maintained. There is a (full) (partial) settlement offer of $ being filed. There is a (full) (partial) settlement offer of $ filed; the style of the case, court, and case number being The proffered settlement should be approved. Unreimbursed medical and other expenses of $ incurred. Attached is a list of such expenses and proposed payees. A reasonable attorney fee for the attorney's services is $ have been and without suit after suit was reimbursement to the attorney for suit expenses is $ . A copy of the attorney's fee contract that has (has not) received prior approval of this Court, subject to modification, and an itemization of suit expenses are attached. The parent(s), , claim $ for damages on account of loss of service of this minor and that claim is included in this settlement offer. FORM 22.0 ­ APPLICATION TO SETTLE A MINOR'S CLAIM 6/1/16 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ____________________ This is a structured settlement. All necessary documents, including a statement of the present value of the settlement, are filed herewith. The applicant requests that: The Court authorize the applicant to execute a release which shall be effective upon payment of the settlement. The Court order payment of the above expenses and order that the net amount of $ for the benefit of the minor be: Deposited in the name of the minor with ,a financial institution, and not to be released until the minor attains the age of majority or upon further order of this Court. Delivered to the legal guardian. Delivered to Delivered to maintained. Structured as set forth in the attached documents. , parent(s) and natural guardian(s). , the person by whom the minor is Supplemental forms required by local rule of Court are attached. __________________________________________ Attorney's Signature __________________________________________ Attorney's Printed Name __________________________________________ Address __________________________________________ City State Zip Code __________________________________________ Telephone Number __________________________________________ Attorney Registration Number __________________________________________ Applicant's Signature __________________________________________ Applicant's Printed Name __________________________________________ Address __________________________________________ City State Zip Code __________________________________________ Telephone Number __________________________________________ Applicant's Email Address FORM 22.0 ­ APPLICATION TO SETTLE A MINOR'S CLAIM 6/1/16 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ____________________ ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets , 20 at o'clock .m., as the date and time for hearing the above application and orders notice to be given by the applicant, as provided in the Rules of Civil Procedure, to the parents who have not waived notice and (further orders that the minor and parent(s) attend the hearing). DATE ALICE O. McCOLLUM, PROBATE JUDGE FORM 22.0 ­ APPLICATION TO SETTLE A MINOR'S CLAIM 6/1/16 American LegalNet, Inc. www.FormsWorkFlow.com