In the Court of Common Pleas of Philadelphia County First Judicial District of Pennsylvania Joint General Court Regulation Trial Division and Orphans’ Court Division No. 97-1 Minors and Incapacitated Person Checklist Settlement/Trial Division Judge: Court Term: Caption: Number: Is this case disposed except for this petition? If yes, how was it disposed? ___Yes ___S.D.& E. ___No ___Jury Trial ___Non-Jury Trial (Incls. Assessment of Damages) ___Other (explain)______________________________________________________________________________________ Consolidated Cases (Indicate Court Term and Number)________________________________________________________ Any Pleadings filed in Orphans’ Court: Yes No Are the following items included in the Petition/Order: Yes No 1. Minor’s/Incapacitated Person’s: a. Date of Birth b. SS# c. Address d. Written approval of settlement if minor is 16 years of age or older 2. Parent(s)/guardian verification attached 3. If guardian of estate was appointed, is Order attached 4. Information concerning mother and father 5. Details concerning the injury 6. Doctor’s report of present condition of minor/incapacitated person 7. Statement from parents and/or guardian certifying the condition of minor/incapacitated person and approval of proposed settlement 8. Counsel’s reasons for approval of proposed settlement 9. Petition signed by counsel 10. Department of Welfare or any other entity lien or claim 11. Does the Order contain the following: a. Itemization of costs for reimbursement b. Counsel fee computed on net settlement c. Affidavit will be filed certifying compliance with the Order d. Amount to minor/incapacitated person (in restricted accounts, typically if under $350,000) e. Amount to Guardian of minor/incapacitated person (typically if over $350,000) I verify the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers. 11-9 (Rev. 5/98) 2002 © American LegalNet, Inc.