PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE IN THE MATTER OF CASE NO. ENTRY APPROVING SETTLEMENT OF A MINOR'S CLAIM Upon hearing the application to approve and distribute the settlement of the claim of the minor, the Court: [check whichever of the following are applicable] Approves the proffered settlement of $ for medical and other expenses, as Orders payment of $ follows: Orders payment of $ suit expenses and $ with respect to this matter; to the attorney for reimbursement of for attorney fees for service rendered to the parent Orders payment of $ for damages on account of loss of service of this minor; Authorizes the applicant to execute a release which, shall be effective upon payment of the settlement; Orders that the net amount of $ , for the benefit of the minor be: Deposited in the name of the minor and not to be released until the minor attains the age of majority or upon further order of this Court with Form 22.3 Verification of Receipt and Deposit filed with the Court; Delivered to the legal guardian of the estate of this minor; , parent Delivered to and natural guardian ; Delivered to person by whom the minor is maintained; , the Structured as set forth in the documents attached to the application; Orders the applicant and the attorney to report on their distribution of the proceeds within thirty days of the date of this entry; Further orders Date William R. Zimmerman, Probate Judge FORM 22.2 - ENTRY APPROVING SETTLEMENT OF A MINOR'S CLAIM 10/01/98 American LegalNet, Inc. www.FormsWorkflow.com