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

PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge Estate of:_________________________________________________________________, Deceased Case No. _____________________________ Date:______________________ REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Pursuant to Entry filed accompanying vouchers. Gross Proceeds Funeral and burial expenses Fiduciary fees to Reimbursement of case expenses to $ Attorney fees to Survival claim to the estate Total Deductions Net Proceeds Net proceeds to beneficiaries: To: To: To: To: To: To: To: Total payments to beneficiaries Balance $ $ $ $ $ $ $ $ $ $ $ $ $ $ , , the proceeds have been paid as shown below and on the $ c c The fiduciary states that there are no other assets remaining in the estate. The fiduciary states that there are assets remaining in the estate. ___ Attorney for Fiduciary Attorney Registration No. FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS Crensch$\forms\14.3 7/26/01 American LegalNet, Inc. www.USCourtForms.com Fiduciary ENTRY The above report of the distribution of the proceeds is hereby approved. There being no further assets to administer, the fiduciary and surety, if any, are discharged. Date Journalized David E. Woessner, Probate Judge American LegalNet, Inc. www.USCourtForms.com