ADDENDUM REGARDING BLOCKED ACCOUNT, ANNUITY, OR TRUST DEPOSIT 1. [ ] The net proceeds of the settlement to the minor or incapacitated person shall be in the form of a check made payable to: [ ] Settlement Guardian ad Litem, [ ] Plaintiff's counsel, [ ] Defense Counsel, [ ] the Clerk of the Court, [ ] the bank where account is open in trust for minor; [ ] the check is to be held by counsel for the _____________________________Insurance Company. [ ] The check shall then be endorsed by the person designated in Paragraph Number 1 and held pending disposition according to the terms of this order by the: [ ] Settlement Guardian ad Litem, [ ] Plaintiff's counsel, [ ] Defense counsel, or [ ] Other: _________________________. [ ] The annuity for the minor shall be purchased by the insurance company which shall file the declarations page. [ ] The [ ] Mother, [ ] Father, [ ] Guardian shall open a blocked account with a state or federally regulated and insured financial institution located in the State of Washington, using the incapacitated person's Social Security number. S/he shall then inform the person designated in Paragraph 5 of the financial institution's name, address, and account number for the blocked account, which person shall then be responsible for the deposit of the check into the blocked account and for the completion and filing of the "Receipt of Funds into Blocked Account." [ ] The [ ] Guardian, [ ] Settlement Guardian ad Litem, [ ] Plaintiff's counsel, [ ] Defense counsel, [ ] Counsel for the ______________________________ insurance company, shall: [ ] Purchase GET/529 credits in the amount of [ ] full amount of settlement amount or [ ] $ [ ] Deposit the funds into a blocked account with a state or federally regulated and insured financial institution located in the State of Washington, using the incapacitated person's Social Security number. [ ] Cause the purchase of an annuity contract consistent with the terms of the foregoing order. [ ] Deposit the funds with a court-approved guardian or trustee and, if the guardian or trustee is constituted in another proceeding, file proof of letters of guardianship or a copy of the trust document. The Settlement Guardian ad Litem shall not be discharged and counsel will not withdraw from the case until the actions specified above are completed and the receipt or copy of annuity contract or letters of guardianship or copy of the trust document has been filed with the court, dismissal of the injury action or civil proceeding notwithstanding. In the event that the [ ] receipt, [ ] annuity declaration page, [ ] trust document [ ] proof of purchase of GET credits is not filed within 30 days of entry of the Order (unless this period is extended by the court, for good cause shown), the persons designated in Paragraphs numbered 2 and 3 shall be required to appear on the Probate Review Calendar and show cause why the blocked account has not been opened, why the funds have not been deposited, why the receipt has not been filed, why the trust document has not been filed, and/or why an annuity has not been purchased. Withdrawals of funds placed in blocked accounts shall not be made except by court order. In the event of any inconsistencies between the terms of the Addendum and the order to which it is attached, the terms of the Addendum shall supersede those of the order. 2. 3. 4. 5. 6. 7. 8. 9. DATED and signed in open court this ___________ day of _________________________, 20______. ___________________________________________ Judge/Court Commissioner ADDENDUM REGARDING BLOCKED BANK ACCOUNT ­ 09/16 American LegalNet, Inc. www.FormsWorkFlow.com