Report Of Distribution Of Wrongful Death And Survival Claims {14.3}

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.PROBATE COURT OF STARK COUNTY, OHIOCalendar No.ESTATE OF, DECEASEDJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)CASE NO.REPORT OF DISTRIBUTION OFWRONGFUL DEATH AND SURVIVAL CLAIMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pursuant to Entry filed below and on the accompanying vouchers. Gross Proceeds$ , the proceeds have been paid as shownTHE PEOPLE OF THE STATE OF NEW YORK TOFuneral and burial expenses$Fiduciary fees to$Reimbursement of case expenses to$GREETINGS:Attorney fees to$WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableSurvival claim to the estate$,Total Deductions$located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomNet Proceeds$$$$Net proceeds to beneficiaries: To: To: To:To:To:To:To:Total payments to beneficiariesYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.$$$, one of the Justices of theCourt in Witness, Honorableday of, 20 County,$$(Attorney must sign above and type name below)Balance-0-Attorney(s) for0 The fiduciary states that there are no other assets remaining in the estate. 0 The fiduciary states that there are assets remaining in the estate.Office and P.O. AddressAttorney for FiduciaryFiduciaryTelephone No.: Facsimile No.: E-Mail Address:Attorney Registration No.Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comFORM 14.3 -REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS4/97COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.ENTRYJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)The above report of the distribution of the proceeds is hereby approved.0 There being no further assets to administer, the fiduciary and surety, if any, are discharged.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DateROBERT D. HOROWITZ -PROBATE JUDGETHE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com</document>