PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE ESTATE OF CASE NO. , DECEASED ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Upon hearing the application to approve settlement and distribution of the wrongful death and survival claims, the Court: Approves the proffered settlement of $ Orders payment of $ expenses. Orders payment of $ to the wrongful death and survival claims. Orders payment of $ and $ wrongful death and survival claims. to be applied to decedent's funeral and burial to the fiduciary for services rendered with respect to the attorney for reimbursement of case expenses for attorney fees for services rendered with respect to the be allocated $ Orders that the net proceeds of $ to the survival claim. The amount to the wrongful death claim and $ allocated to the survival claim shall be considered an asset of the estate and shall be reflected in the fiduciary's account of the administration of the estate. Finds all of the beneficiaries of the wrongful death claim are on an equal degree of consanguinity, are adults, and have agreed how the net proceeds allocated to the wrongful death claim are to be distributed. Orders distribution of the net proceeds allocated to the wrongful death claim to the surviving spouse, children, parents and other next of kin, in the equitable shares shown below, fixed by the Court having due regard for the injury and loss to each beneficiary resulting from the death and for the age and condition of the beneficiaries. Name Residence Address Relationship to Decedent Birthdate of Minor Amount FORM 14.2 - ENTRY APPROVING SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 09/1/2011 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. Orders that the share of: a minor(s) be deposited pursuant to R.C. 2111.05. a minor(s) be paid to the guardian of the estate of such minor. a child(ren) be deposited in a trust for the benefit of the child(ren) until twenty-five years of age. Authorizes the fiduciary to execute a release which, upon payment, shall be a discharge of the claim. Orders the fiduciary and the attorney to report the distribution of the proceeds within thirty days of the date of this Entry. Further orders Approved: Attorney for Fiduciary Dixie Park - Probate Judge Attorney Registration No. Date American LegalNet, Inc. www.FormsWorkFlow.com