PROBATE COURT OF ___________________ COUNTY, OHIO IN THE MATTER OF ________________________________________________________ CASE NO. ___________________ APPLICATION TO SETTLE A MINOR'S CLAIM [R.C. 2111.05, R.C. 2111.18, SUP. R. 67 AND 68] [Check applicable boxes, complete applicable blanks, strike inapplicable language, and attach supporting documentation.] The applicant states that: _________________________________________, is an unemancipated minor, born _________________, ______, residing at ______________________________________________ in this county who on or about ____________________________, ______, suffered personal injury (and damage to this minor's property) by wrongful act, neglect, or default that entitles this minor to maintain an action to recover damages. A copy of the birth certificate is attached. Attached is a narrative statement in support of the proffered settlement setting forth a description of the occurrence, the injury or damage, the treatment progress and current prognosis by the treating physicians, and other proposed or actual settlements resulting from the same occurrence being paid to persons other than this minor. Counsel will advise at the hearing as to liability and collectability. There is no legal guardian of the estate, and the Court may authorize the settlement without the appointment of a guardian. _________________________________ is the legal guardian of the estate. Case No. ______________ _________________________________ is (are) the parent__ and natural guardian__. _________________________________ is the person by whom the minor is maintained. There is a (full) (partial) settlement offer of $ ________________________ without suit being filed. There is a (full) (partial) settlement offer of $ _________________________ after suit was filed; the style of the case, court, and case number being ___________________________________________. The proffered settlement should be approved. Unreimbursed medical and other expenses of $ ________________________ have been incurred. Attached is a list of such expenses and proposed payees. A reasonable attorney fee for the attorney's services is $ _________________________ and reimbursement to the attorney for suit expenses is $ _________________________. A copy of the attorney's fee contract that has (has not) received prior approval of this Court, subject to modification, and an itemization of suit expenses are attached. FORM 22.0 - APPLICATION TO SETTLE A MINOR'S CLAIM AND ENTRY SETTING HEARING 10/1/98 American LegalNet, Inc. www.FormsWorkflow.com (Reverse of Form 22.0) The parent_ , ___________________________________, claim $ _________________ for damages on account of loss of service of this minor and that claim is included in this settlement offer. This is a structured settlement. All necessary documents, including a statement of the present value of the settlement, are filed herewith. The applicant requests that: The Court authorize the applicant to execute a release which shall be effective upon payment of the settlement. The Court order payment of the above expenses and order that the net amount of $ ________________________ for the benefit of the minor be: Deposited in the name of the minor with __________________________ ____________________________________________, a financial institution, and not to be released until the minor attains the age of majority or upon further order of this Court. Delivered to the legal guardian. Delivered to ___________________________________________, parent__ and natural guardian__. Delivered to ________________________________________________, the person by whom the minor is maintained. Structured as set forth in the attached documents. Supplemental forms required by local rule of Court are attached. _________________________________ Attorney for Applicant ________________________________________ Applicant _________________________________ Typed or Printed Name _________________________________ ________________________________________ Typed or Printed Name ________________________________________ _________________________________ Address _________________________________ Phone Number (include area code) ________________________________________ Address ________________________________________ Phone Number (include area code) Attorney Registration No. ____________ ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets _____________________________, at __________ o'clock __.m. as the date and time for hearing the above application and orders notice to be given by the applicant, as provided in the Rules of Civil Procedure, to the parents who have not waived notice and (further orders that the minor and parent_ attend the hearing.) ____________________________________ Probate Judge American LegalNet, Inc. www.FormsWorkflow.com