5-19-16 FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY Trial Division - Civil1 : : : : : TERM, 20 NO. PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTIONS To The Honorable, the Judges of the Said Court: The Petition of ________________________, Administrator/Executor of the Estate of __________________, Deceased, by his/her attorney, ______________________, Esquire, respectfully requests: 1. Petitioner is ____________________ who was appointed Administrator/Executor of the Estate of _____________________, Deceased, on__________________, ____, by the Register of Wills of _________________ County. A copy of the Decree of the Register is attached. 2. The plaintiff decedent died on ____________________ as a result of (set forth relevant information describing the underlying negligence or cause of action as required by Phila. Civ. R. 2206(D)): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (If additional space is needed, please continue on separate sheet). 3. Notice of the institution of the action as required by Pa. R.C.P. 2205 and Philadelphia Civ. R. 2206 (E) was given on _______________________ to the following individuals: NAME ______________________________ ______________________________ ______________________________ ADDRESS: _____________________________ _____________________________ _____________________________ 4. 1 Pursuant to Phila. Civ. R. 2206 (E) Petitioner has served a copy of this Petition on the In the event the Petition is filed in the Orphans' Court Division, the caption must comply with Pa.O.C. 3.2. American LegalNet, Inc. www.FormsWorkFlow.com 5-19-16 intestate heirs2 of plaintiff decedent (as provided in 20 Pa. C.S. §2101 et seq.) who are as follows: NAME _____________________ _____________________ _____________________ RELATIONSHIP ________________ ________________ ________________ ADDRESS _______________________ ________________________ ________________________ 5. Pursuant to Phila. Civ. R. 2206(E) Petitioner has served a copy of this Petition on the following parties who may have a possible interest: NAME _____________________ _____________________ _____________________ 6. RELATIONSHIP ADDRESS ________________ _________________________ ________________ _________________________ ________________ _________________________ Decedent (did) (did not) have a Will. A copy is attached. 7. The following unpaid claims3 have been raised and/or are outstanding in the decedent's estate: CREDITOR _______________________________ _______________________________ _______________________________ AMOUNT DUE __________________________ __________________________ __________________________ 8. A Complaint was filed against defendant(s) as follows: _______________________________________________________________________________ _______________________________________________________________________________. 9. The following settlement has been proposed4: _________________________________________________________________________ 2 In the event any court has appointed a guardian for a minor heir or incapacitated person, set forth the name of the guardian, the Court date and manner of appointment. 3 Petitioner must indicate whether the Department of Human Services has a claim or a lien against Petitioners, the Estate or any wrongful death beneficiaries. 4 In the event a portion of the settlement is payable through the purchase of an annuity, set forth the credit rating of the entity which assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments sought American LegalNet, Inc. www.FormsWorkFlow.com 5-19-16 _________________________________________________________________________ (If additional space is needed, please continue on a separate page). 10. Counsel is of the professional opinion that the proposed settlement is reasonable due to the following (state the reasons why in the professional opinion of counsel the settlement is proper): ______________________________________________________________________________ ______________________________________________________________________________ (If additional space is needed, please continue on separate page). 11. Petitioner is of the opinion that the proposed settlement is reasonable. 12. Counsel has incurred the following expenses for which reimbursement is sought (Please set forth in detail): _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (If additional space is needed, please continue on separate page). 13. Counsel requests counsel fees in the amount of $___________ which represents _____% of the net proceeds of the settlement. 14. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorneys fees) as follows: a. b. 15. Wrongful Death Claim$_________________ Survival Claim $_________________ The reason for the requested allocation are as follows: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (If additional space is needed, please continue on a separate page). 16. Pursuant to the Wrongful Death Statute (42 Pa. C.S. §8301), the beneficiaries of the Wrongful Death Claim, and the proportion of their interest, are as follows: NAME __________________________________ __________________________________ AMOUNT DUE ________________________ ________________________ American LegalNet, Inc. www.FormsWorkFlow.com 5-19-16 17. The pecuniary loss suffered by the beneficiaries listed in Paragraph 16 is as follows: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________ (If additional space is needed, please continue on a separate page). WH