PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE IN RE: GUARDIANSHIP OF CASE NO. IN THE MATTER OF CASE NO. PROPOSAL FOR MINOR SETTLEMENT DATE OF BIRTH AGE OF MINOR NAME OF FATHER NAME OF MOTHER ADDRESS OF CUSTODIAN NAME OF ATTORNEY (PLAINTIFF) NAME OF ATTORNEY (DEFENDANT) BRIEF DESCRIPTION OF INJURY NATURE OF ACCIDENT POLICY LIMITS $ SUIT FILED YES NO VERDICT $ OFFER OF SETTLEMENT $ DID THE PARENTS RECEIVE MONEY IN THIS OR A RELATED CASE? YES NO MINOR'S S.S. # IF YES HOW MUCH $ EXPENSES MEDICAL EXPENSE $ HOSPITAL EXPENSE TO PARENTS ATTORNEY FEE ( %) NET TO MINOR STRUCTURED YES NO PRESENT VALUE OF STRUCTURE BEST RATING OF ANNUITY UNDERWRITER $ WILL MINOR BE PRESENT? YES NO WILL BOTH PARENTS BE PRESENT? YES NO NO WILL DOCTOR'S DISCHARGE LETTER BE PRESENTED? YES WILL TORTFEASOR'S ATTORNEY BE PRESENT? YES WILL FUNDS BE IMPOUNDED? YES DATE NO NO ATTORNEY FOR CLAIMANT DETAILS OF STRUCTURE ATTACHED American LegalNet, Inc. www.FormsWorkflow.com