PROBATE COURT OF STARK COUNTY, OHIO IN THE MATTER OF CASE NO. REPORT OF DISTRIBUTION MINORS CLAIM Pursuant to Entry filed , the proceeds have been paid as shown below and on the accompanying vouchers. 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 $ -0- Attorney for Applicant Applicant Attorney Registration No. ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. Date Dixie Park, Probate Judge American LegalNet, Inc. FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY MINORS CLAIM 4/97 www.USCourtForms.com