PROBATE COURT OF ________________ COUNTY, OHIO ESTATE OF _______________________________________________________, DECEASED CASE NO. _______________________ REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry filed _______________________________, _______, the proceeds have been paid as shown 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$ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _______________________________ $ _______________________________ $ _________________________ $ _________________________ _________________________________________ Attorney for Fiduciary Attorney Registration No. ____________________ _________________________________ Fiduciary 4/1/97 FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 14.3) 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 Print Form American LegalNet, Inc. www.FormsWorkFlow.com