PROBATE COURT OF WARREN COUNTY, OHIO IN THE MATTER OF CASE NO. REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM Pursuant to Entry filed below and on the accompanying vouchers. Gross Proceeds Less: Medical expenses Reimbursement of suit expenses to Attorney fees to Loss of service to Other: Total Net Proceeds Deposited pursuant to R.C. 2109.13 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 $ $ $ $ $ $ , , the proceeds have been paid as shown $ $ $ $ $ $ $ -0- Attorney for Applicant Attorney Registration No. Applicant ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. Date Probate Judge FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM 4/97 American LegalNet, Inc. www.USCourtForms.com