PROBATE COURT OF SUMMIT COUNTY, OHIO ESTATE OF CASE NO. , DECEASED REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry filed and on the accompanying vouchers. Gross proceeds Funeral and burial expenses Fiduciary fees to Reimbursement of case expenses to Attorney fees to Survival claim to the estate Net Proceeds Net proceeds to beneficiaries: To: To: To: To: To: To: To: Total payments to beneficiaries Balance , the proceeds have been paid as shown below $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -0- G The fiduciary states that there are no other assets remaining in the estate. G The fiduciary states that there are assets remaining in the estate. Attorney for Fiduciary Fiduciary ENTRY The above report of the distribution of the proceeds is hereby approved. G There being no further assets to administer, the fiduciary and surety, if any, are discharged. IT IS SO ORDERED. Date Form 14.3 JUDGE ELINORE MARSH STORMER American LegalNet, Inc. www.FormsWorkFlow.com