PROBATE COURT OF SUMMIT COUNTY, OHIO ELINORE MARSH STORMER, JUDGE IN THE MATTER OF CASE NO. , MINOR APPLICATION TO SETTLE A MINOR'S CLAIM (R.C. 2111.05, R.C. 2111.18, Sup.R. 67 and 68) Now comes the undersigned applicant and states that is a minor who is a resident of Summit County, Ohio, and who is The names and address of the minor child's parent(s) is/are: Mother: years old. Father: The minor child resides at with who is/are: his/her parent(s) and natural guardian(s). his/her custodian(s) pursuant to an Order of the Juvenile Court, and a copy of said Order is attached. his/her guardian(s). The applicant states that the minor child is entitled to maintain an action for damages or any other relief based on any claim, the specific details of which are as follows: and Attached is a current statement of the examining physician in respect to the injuries sustained, the extent of recovery thereof, and the physician's prognosis. The applicant request authority to adjust and settle the claim of said minor with the advice, approval, and consent of the Probate Court as follows: Gross Settlement Attorney Fees: Medical Expenses: Other: Net to Minor: The parent(s) of the minor waive all claims for damages for loss of services of the minor. The applicant requests that attorney fees as applied for be approved in that the fees were reasonable and beneficial to the minor's estate. FORM 22 ­ APPLICATION TO SETTLE A MINOR'S CLAIM PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com Rev. 02/02/2017 CASE NO. The applicant states that no person has been appointed guardian of said minor's estate, and that the net estate to the minor does not exceed $25,000.00, and requests that the appointment of a guardian be dispensed with pursuant to R.C. 2111.18. The applicant states that has been appointed guardian of . the minor child's estate in Summit County Probate Court, Case No. The applicant requests that the minor's estate be distributed as follows: Delivered to the custodian of said minor to be expended for the minor's benefit. Delivered to the legally-appointed Guardian of said minor to be accounted for in the Guardian's Account. Deposited in a local banking institution in the name of the minor, impounding both the principal and interest and releasing said funds to the minor at the age of majority or upon further Order of the Court. Applicant acknowledges that he/she will file a verification of deposit with this Court within seven (7) days of receipt of said funds. Attorney for Applicant Signature Typed or Printed Name Address Phone Number (Include Area Code) Attorney Registration Number Applicant Signature Typed or Printed Name Address Home Phone Number (Include Area Code) Work Phone Number (Include Area Code) CONSENT The undersigned parent(s) and natural guardian(s) of the minor child consent to the approval of the within Application. Mother Signature Type or Print Name Father Signature Type or Print Name FORM 22 ­ APPLICATION TO SETTLE A MINOR'S CLAIM PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com Rev. 02/02/2017