PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE IN THE MATTER OF CASE NO. REPORT OF DISTRIBUTION MINOR'S CLAIM Pursuant to Entry filed paid as shown below and on the accompanying vouchers. , the proceeds have been 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 22.3 attached $ Delivered to legal guardian of the estate $ Delivered to parent and natural guardian $ Delivered to the person by whom the minor is maintained $ Structured - see documents previously filed $ Balance $ Attorney for Applicant -0- Applicant Attorney Registration No. ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. Date William R. Zimmerman, Probate Judge FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM 04/01/97 American LegalNet, Inc. www.FormsWorkflow.com