PROBATE COURT OF WARREN COUNTY, OHIO ESTATE OF CASE NO. REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry filed below 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 Total Deductions Net Proceeds Net proceeds to beneficiaries: To: To: To: To: To: To: To: Total payments to beneficiaries Balance The fiduciary states that there are no other assets remaining in the estate. The fiduciary states that there are assets remaining in the estate. $ $ $ $ $ $ $ $ -0$ $ $ $ $ $ , , the proceeds have been paid as shown $ , DECEASED Attorney for Fiduciary Attorney Registration No. Fiduciary FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS 4/97 American LegalNet, Inc. www.USCourtForms.com ENTRY The above report of the distribution of the proceeds is hereby approved. There being no further assets to administer, the fiduciary and surety, if any, are discharged. Date PROBATE JUDGE American LegalNet, Inc. www.USCourtForms.com