Application To Settle A Claim Of An Adult Ward {22.5}

PROBATE COURT OF________________ COUNTY, OHIO _____________, JUDGE IN THE MATTER OF_________________________________________________ CASE NO.____________________ APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD [R.C. 2111.18, Sup.R. 69] [Check applicable boxes, complete applicable blanks, strike inapplicable language, and attach supporting documentation.] The applicant states that:_____________________________________________________, is an adult ward residing at __________________________________________________in this county who on or about ___________________________, suffered personal injury and/or damage to property by wrongful act, neglect, or default that entitles this person to maintain an action to recover damages. Attached is a narrative statement in support of the proffered settlement setting forth a description of the occurrence, the injury or damage, the treatment progress and current prognosis by the treating physicians, and other proposed or actual settlements resulting from the same occurrence being paid to the persons other than this ward. Counsel will advise at the hearing as to liability and collectability. There is a (full) (partial) settlement offer of $______________________ without suit being filed. There is a (full) (partial) settlement offer of $_______________________after suit was filed; the style of the case, court, and case number being _______________________________________. The proffered settlement should be approved. Unreimbursed medical and other expenses of $________________________ have been incurred. Attached is a list of such expenses and proposed payees. A reasonable attorney fee for the attorney's services is $_______________________ and reimbursement to the attorney for suit expenses is $_________________________. A copy of the attorney's fee contract that has (has not) received prior approval of this Court, subject to modification, and an itemization of suit expenses are attached. This is a structured settlement. All necessary documents, including a statement of the present value of the settlement, are filed herewith. FORM 22.5 ­ APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD Effective Date: January 1, 2015 American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 22.5] CASE NO. ________________ Applicant requests that: The Court authorize the applicant to execute a release which shall be effective upon payment of the settlement. The Court order payment of the above expenses and order that the net amount of $_________________________ for the benefit of the ward be: Deposited in the name of the ward with ____________________________________ _______________, a financial institution, in a restricted account and not be released without written order of this Court. Delivered to guardian of the estate. Structured as set forth in the attached documents. Other: _____________________________________________________________. Supplemental forms required by local rule of Court are attached. _________________________________ Attorney for Applicant _________________________________ Typed or Printed Name _________________________________ _________________________________ Address __________________________________ Phone Number (include area code) Attorney Registration No. _____________ ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets ___________________________, at ________ o'clock ___.m. as the date and time for hearing the above application and orders notice to be given by the applicant, as provided in the Rules of Civil Procedure, to all interested parties. ________________________________ _______________, PROBATE JUDGE FORM 22.5 ­ APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD Effective Date: January 1, 2015 American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ Applicant ______________________________ Typed or Printed Name ______________________________ ______________________________ Address ______________________________ Phone Number (include area code)