5-19-16 FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY Trial Division - Civil : TERM, 20 : : : No: O R D E R AND NOW, this day of , 20 , upon consideration of the Petition to Compromise Wrongful Death and Survival Action filed on , 20, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant(s) , in the gross sum of ($) Dollars. Defendant(s) shall forward all settlement drafts or checks to Petitioner's counsel for proper distribution. IT IS FURTHER ORDERED and DECREED that the settlement proceeds are allocated as follows: 1. Wrongful Death $ 2. Survival Claim $ IT IS FURTHER ORDERED and DECREED that the settlement proceeds be distributed as follows: 1. To: , Esquire $ For Costs 2. To: , Esquire $ For Counsel Fees 3. The Wrongful Death Claim in the sum of $ shall be paid as follows: a. To: Spouse; and/or $ American LegalNet, Inc. www.FormsWorkFlow.com 5-19-16 b. To: Adult Child(ren);7 and/or $ c. To: Minor Child(ren)8 $ as provided hereunder OPTION 1 To: , Guardian of the Estate of , a minor; provided, however, that no payment shall be made to the guardian until the guardian has posted additional security as may be required by the Orphans' Court Division of County pursuant to 20 Pa. C.S. 2475121, et seq. An appropriate Petition shall be filed with the Orphans' Court within thirty (30) days. OPTION 2 Counsel is hereby authorized to execute all documentation necessary to purchase saving certificate(s), from federally insured banks or savings institutions having an office in Philadelphia County, in the sum of $, each not to exceed the insured amount, with the funds payable to the minor upon majority. The certificate shall be titled in the name of the minor and shall be restricted as follows: Not to be redeemed except for renewal in its entirety, not to be withdrawn, assigned, negotiated, or, otherwise alienated before the minor attains majority, except upon prior Order of Court.Counsel shall open a savings account in the sum of $in the name of the minor. The savings account shall be restricted as follows: Not to be withdrawn before the minor attains majority, except for the payment of city, state, and federal income taxes on the interest earned by the savings certificate and savings account, or upon prior Order of Court. c. To: Parent(s) $ 7In the event the beneficiary is an incapacitated person, appropriate changes are to be made. 8In the event part of the settlement proceeds are payable through the purchase of an annuity, the terms of the annuity shall be set forth in the Order. American LegalNet, Inc. www.FormsWorkFlow.com 5-19-16 4. The Survival Claim in the sum of $shall be paid to , Administrator/Executor, of the Estate of , Deceased; provided, however, that counsel shall not distribute any funds to the said Administrator/Executor until the additional security as may be required by the Register of Wills of County pursuant to 20 Pa. C.S. 2473323(b)(3) is posted. Within sixty (60) days of the entry of this final Order, counsel shall file with the office of Civil Administration an Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of the Certificate of Deposit and/or bank account containing the required restrictions. BY THE COURT: J. ORPHANS' COURT DIVISION cc: Register of Wills of County. American LegalNet, Inc. www.FormsWorkFlow.com