PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE ESTATE OF , DECEASED CASE NO. APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, 2125.03, 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 the case number being . A judgment has been recovered for damages for 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 $ . This 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's services is $ itemization of such services is attached. and an and A reasonable attorney fee for the attorney's services is $ . A copy of the reimbursement to the attorney for case expenses is $ attorney's fee contract that (has) (has not) received prior approval of this Court, subject to modification, and an itemization of case expenses are attached. The net proceeds of $ wrongful death action and $ support thereof is attached. to the should be allocated $ the survival action. A statement in 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 an equal degree of consanguinity, are adults, and have agreed how the net proceeds are to be distributed. The beneficiaries of the wrongful death action are not on an 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. H.C. FORM 14.0 - APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF Page 1 of 2 WRONGFUL DEATH AND SURVIVAL CLAIM 10/01/98 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. The surviving spouse, children, and parents of the decedent and 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 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 Fiduciary Attorney Registration No. Page 2 of 2 H.C. FORM 14.0 - APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH SURVIVAL CLAIM American LegalNet, Inc. www.FormsWorkflow.com