PROBATE COURT OF ___________________ COUNTY, OHIO IN THE MATTER OF ___________________________________________________ CASE NO. ___________________ REPORT OF DISTRIBUTION MINOR'S CLAIM Pursuant to Entry filed _____________________________, ______, the proceeds have been paid as shown 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 _________________________________________ Attorney for Applicant Attorney Registration No. __________________ ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. $_____________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ _____________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ -0_______ ________________________________________ Applicant ______________________________ Date _________________________________________ Probate Judge Print Form FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM 4/1/97 American LegalNet, Inc. www.FormsWorkFlow.com