Worksheet- Checklist For Compromise Applications

WORKSHEET/CHECKLIST FOR COMPROMISE APPLICATIONS Court Use Only - Do Not Write In This Box Index No. ______________________ Date Application Submitted _______ Hearing Date __________ Date Order Signed NAME OF INFANT/IMPAIRED PERSON __________________________________ Residence: ________________________ ________________________ Age & D.O.B For a Structured Settlement Life Expectancy NAME OF PETITIONER: Residence ATTORNEY OF RECORD FOR PETITIONER: Address Phone No. Fax No. ________________ E-Mail Address ____________ Years Rated Age (if used) ________ Relationship ______________ Phone No.________________ Date of Injury ATTORNEY APPEARING AT HEARING Address __________________________ Phone No. THE APPLICATION AND ORDER Read The Rules and Use the Court's Forms Make certain that all information required by law and the court's rules is set forth in the proposed order and in the supporting papers. It is strongly recommended, therefore, that, before filing an application, the court's rules and instructions be read and that the forms provided by this Court on the OCA Website1 be utilized! This worksheet /checklist only provides an outline for your guidance. Be Consistent Make certain that all information in this worksheet is also included in the formal application submitted to the Court, and that the information contained in both the application and worksheet is consistent. The Website address is www.nycourts.gov/courts. Go to Trial Courts and scroll across and down to New York City, and then down to Bronx 12th JD. Click on Bronx 12th JD, then on Civil Divisions and then on City Part. 1 American LegalNet, Inc. www.FormsWorkflow.com 1 PROPOSED SETTLEMENT COST G G ($_____________________)2 If a structured settlement is being proposed please provide details on the next page. If more than one defendant is contributing to the settlement please provide an explanation and an apportionment of the settlement proceeds. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ PROPOSED DISTRIBUTION OF SETTLEMENT PROCEEDS UP FRONT AMOUNTS (1) Counsel Fees (2) Legal Disbursements (3) Other Disbursements Doctor Liens Other (4) Up Front Cash to Infant COST TO FUND ANNUITY TOTAL SETTLEMENT COST Proposed $ $ $ $ $ $ $ $ $ Allowed $ $ $ $ $ $ $ $ ___________ $__________ For the ordinary settlement the cost to the defendant and the total settlement payout are identical. However, for a structured settlement the "total settlement payout" and the "settlement cost" are different. For a structured settlement, the "total settlement payout" is the sum of all periodic payments (itemized on the next page) plus the up front amounts listed above. For a structured settlement, the "cost" of the settlement to the defendant is the sum of the up front amounts listed above, plus the sum expended to purchase the annuity. For a structured settlement, it is essential, for income tax purposes, that the documents clearly identify and distinguish both amounts. 2 American LegalNet, Inc. www.FormsWorkflow.com 2 PROPOSED STRUCTURED SETTLEMENT TOTAL SETTLEMENT PAYOUT Up-front Amounts Total All Periodic Payments TOTAL PAYOUT PROPOSED PERIODIC PAYMENTS: $ $ $_________________ Payable as follows: (1) The sum of ($__________) per month for the life of the plaintiff [increasing by ____% year compounded annually], for a per guaranteed minimum of _______ years, with the first payment on ________ and the last guaranteed payment on _________; and (2) A guaranteed payment of (3) A guaranteed payment of (4) A guaranteed payment of (5) A guaranteed payment of (6) A guaranteed payment of (7) A guaranteed payment of (8) Non guaranteed life payments ($ ________________) on ___________; and ($ ________________) on ___________; and ($ ________________) on ___________; and ($ ________________) on ___________; and ($ ________________) on ___________; and ($________________) on ___________; ($________________; to full life expectancy $________________ $ ________________3 NAMES _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ TOTAL GUARANTEED PAYMENTS TOTAL PERIODIC PAYMENTS PARTIES TO THE TRANSACTION (1) Plaintiff/Payee of Annuity (2) Defendants/Assignors; (3) Annuity Owner/ Assignee (4) Annuity Issuer (5) Guarantor ADDITIONAL REQUIRED SETTLEMENT DOCUMENTS G Affidavit of Structure Broker; G Settlement Agreement; G Assignment Agreement; G Annuity Contract; G Guaranty Agreement This amount should include the total of all proposed periodic payments i.e., nonguaranteed life payments to full life expectancy as well as guaranteed payments. 3 American LegalNet, Inc. www.FormsWorkflow.com 3 THE AFFIRMATION AND AFFIDAVIT OF COUNSEL AND PETITIONER Retainer No. Date filed [UCR 202.67(d)] The supporting affidavit by counsel must recite (check those that apply) 9 that counsel has utilized one of the court's proposed form orders; 9 that counsel has read and has fully complied with the court's rules for settlement of claims made by infants/impaired persons; and that counsel's affirmation and petitioners affidavit contains all information required by CPLR 1207, 1208 AND UCR 202.67; and for structured settlements, GOL §§ 5-1700 et seq. 9 that petitioner is qualified and authorized by CPLR 1207 to bring the application; 9 that all services rendered and details which support the claim for counsel fees and disbursements have been described;[CPLR 1208 (b) and UCR 202.67 (a)], 9 that all other claims or other circumstances which might possibly result in a conflict of interest, have been identified; 9 that all medical services rendered, amounts paid, by whom paid, amounts remaining unpaid and possible liens have been identified; and documentation regarding same has been appended to the application; 9 that counsel has made personal efforts to ascertain if the infant/impaired person currently has, or in the recent past has had, any limitations or complaints of pain which may be related to the injuries sustained in this action. 9 that petitioner's affidavit contains an acknowledgment of: 9 9 9 the reasons given by counsel for recommending settlement; the proposed distrib