PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE IN THE MATTER OF CASE NO. APPLICATION TO SETTLE A MINOR'S CLAIM [R.C. 2111.18, C.P. 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 , residing at about , suffered personal injury (and damage to this minor's property) by wrongful act, neglect, or default that entities 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 and natural guardian is the person by whom the minor is maintained. There is a (full) (partial) settlement offer of $ There is a (full) (partial) settlement offer of $ filed; the style of the case, Court, and case number being without suit being filed. after suit was The proffered settlement should be approved. Unreimbursed medical and other expenses of $ incurred. Attached is a list of such expenses and proposed payees. have been and A reasonable attorney fee for the attorney's services is $ A copy of reimbursement to the attorney for suit expenses is $ 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. Page 1 of 2 FORM 22.00 - APPLICATION TO SETTLE A MINOR'S CLAIM 10/01/98 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. for damages The parent , claim $ , on account of loss of service of this minor and that claim is included in settlement offer. 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 pursuant to R.C. 2111.05 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 natural guardian parent and Delivered to whom the minor is maintained. , the person by Structured as set forth in the attached documents. Supplemental forms required by local rule of Court are attached. Attorney for Applicant Applicant Typed or Printed Name Typed or Printed Name Address Address Phone Number (include area code) Phone Number (include area code) Attorney Registration No. Page 2 of 2 FORM 22.00 - APPLICATION TO SETTLE A MINOR'S CLAIM American LegalNet, Inc. www.FormsWorkflow.com