PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE ESTATE OF ________________________________________________, DECEASED CASE NO. ___________________________ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, 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 case number being ___________________________________________________________. A judgment has been recovered for damages for the 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 $___________________________________. There 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 for services rendered is $_____________________________ and an itemization of such services is attached. Outstanding hospital and medical bills in the amount of $_____________________________ and an itemization of such bills is attached. Outstanding claims to a right of subrogation for the payment of hospital and medical bills in the amount of $_____________________________ and an itemization of such is attached. A reasonable attorney fee for the attorney's services is $__________________________________ and reimbursement to the attorney for case expenses is $_____________________________. A copy of the attorney's fee contract that (has) (has not) received prior approval of the Court, subject to modification, and itemization of the case expenses are attached. Other: _______________________________________________________________________________ ____________________________________________________________________________________. The net proceeds of $____________________ should be allocated $_________________ to the wrongful death action and $____________________ to the survival action. A statement in support thereof is attached. FORM 14.0 ­ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Amended: January 1, 2015 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 14.0] CASE NO. _____________________ 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 equal degree of consanguinity, are adults, and have agreed how the net proceeds allocated to the wrongful death claim are to be distributed. The beneficiaries of the wrongful death action are not all on 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. The surviving spouse, children, and parents of the decedent and the 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 Relationship Birthdate Amount Address to Decedent of Minor ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ The survival claim beneficiaries are as follows: ________________________________________________________________________________________ Name Residence Relationship Birthdate Amount Address to Decedent 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 Attorney Registration No. _______________ ____________________________________ Fiduciary ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets ___________________________________ at _____________ o'clock _____.m. as the date and time for hearing the above application and orders notice to be given by the fiduciary, as provided in the Rules of Civil Procedure, to the wrongful death and survival claim beneficiaries who have not waived notice. __________________________________________ Dixie Park, Probate Judge FORM 14.0 ­ APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Amended: January 1, 2015 American LegalNet, Inc. www.FormsWorkFlow.com Discard all previous versions of this form