PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE IN THE MATTER OF: CASE NO.: REPORT OF DISTRIBUTION MINOR'S CLAIM Pursuant to the Entry filed paid as shown below and on the accompanying vouchers. Gross Proceeds Less: Medical expenses Reimbursement of suit expenses to $ Attorney fees to Loss of service to: Others: Total Net Proceeds Deposited pursuant to R.C. 2111.05 Form 22.3A attached Delivered to legal guardian of the estate Delivered to parent(s) and natural guardian(s) Delivered to the person by whom the minor is maintained Structured ­ see documents previously filed $ $ $ $ $ $ -0$ $ $ $ $ , $ , the proceeds have been Balance Attorney for Applicant Attorney Registration No. Applicant American LegalNet, Inc. www.FormsWorkFlow.com FORM 22.4 ­ REPORT OF DISTRIBUTION MINOR'S CLAIM 6/1/16 CASE NO. ____________________ ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. DATE ALICE O. McCOLLUM, PROBATE JUDGE American LegalNet, Inc. www.FormsWorkFlow.com FORM 22.4 ­ REPORT OF DISTRIBUTION MINOR'S CLAIM 6/1/16