Application To Settle A Minors Claim {22.0}

MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF ___________________________________________________ CASE NO. ______________________ APPLICATION TO SETTLE A MINOR'S CLAIM [R.C. 2111.05, R.C. 2111.18, SUP.R. 67 AND 68] [Check applicable boxes complete applicable blanks, strike applicable language, and attach supporting documentation.] The applicant states that: ______________________________, is an unemancipated minor, born ___________, _____, residing at ___________________________ in this county who on or about ____________________, ______, suffered personal injury (and damage to this minor's property) by wrongful act, neglect, or default that entitles this minor to maintain an action to recover damages. A copy of the birth certificate is attached. 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 persons other than this minor. Counsel will advise at the hearing as to liability and collectability. There is no legal guardian of the estate, and the Court may authorize the settlement without the appoint of a guardian. ____________________________ is the legal guardian of the estate. Case No. __________ ____________________________ is (are) the parent __ and natural guardian __ . ____________________________ is the person by whom the minor is maintained. 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. FORM 22.0 ­ APPLICATION TO SETTLE MINOR'S CLAIM AND ENTRY SETTING HEARING American LegalNet, Inc. www.FormsWorkFlow.com The parent__, ______________________________, claim $ ____________ for damages on account loss of service of this minor and that claim is included in this settlement offer. This is a structured settlement. All necessary documents, including a statement of the present value of the settlement, are filed herewith. The 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 minor be: Deposited in the name of the minor with ____________________________________, a financial institution, and not be released until the minor attains the age of majority or upon further order of this Court. Delivered to the legal guardian. Delivered to _________________________________, parent __ and natural guardian _. Delivered to _____________________________, the person by whom the minor is maintained. Structured as set forth in the attached documents. Supplement 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. __________ _______________________________ Applicant _______________________________ Typed or Printed Name _______________________________ _______________________________ Address _______________________________ Phone Number (include area code) ENTRY SETTING HEARING AND ORDER 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 the parents who have not waived notice and (further orders that the minor and parent __ attend the hearing.) ________________________________ Probate Judge Print Reset American LegalNet, Inc. www.FormsWorkFlow.com