COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTYFIRST JUDICIAL DISTRICTPLAINTIFF:CIVIL TRIAL DIVISION:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v.:TERM, 20:DEFENDANT:NO.THE PEOPLE OF THE STATE OF NEW YORK TOPETITION FOR LEAVE TO SETTLE ORCOMPROMISE MINOR'S ACTION1To The Honorable, the Judges of the Said Court:The Petition of , a minor, by his Guardian (see Pa.R.C.P. 2028), by his attorney, , Esquire respectfully requests:GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable1. Petitioner is (see Pa.R.C.P. 2026): . 2. The minor was born on , and his/her social security number is .,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 room3. The minor resides with at the following address: .4. A guardian (was) (was not) appointed for the minor as follows: . A copy of the Order is attached.Your 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.5. The minor's mother is who resides at the following address: .6. The minor's father is who resides at the following address: ., one of the Justices of theCourt in Witness, Honorableday of, 20 County,7. The defendant is who resides or whose principal place of business at all relevant times was .(Attorney must sign above and type name below)8. On the minor sustained the following injuries at the following location (set forth in detail): Attorney(s) for (If additional space is needed, please continue on separate page).9. A Complaint was filed against defendant(s) as follows: .Office and P.O. Address1 In the event the Petition involves an Incapacitated Person, appropriate changes are to be made. See Pa.R.C.P. 2051, et seq.Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)10. Attached hereto is a report by Dr. dated which sets forth the present condition of the minor.11. Attached hereto is a statement, under oath, of the minor's parents and/or guardian and/or guardian ad litem certifying the physical and/or mental condition of the minor, as well as the parents' and/or guardian's and/or guardian ad litem's approval of the proposed settlement and distribution.12. Attached hereto is thewritten approvalof theproposed settlementanddistributionbytheminor,who issixteen (16) years of age or older.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TO13. The following settlement has been proposed2: (If additional space is needed, please continue on separate page.)GREETINGS:14. Counsel is of the professional opinion that the proposed settlement is reasonable due to the following: (If additional space is needed, please continue on separate page.)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 room15. Counsel has incurred the following expenses for which reimbursement is sought (please set forth in detail) (If additional space is needed, please continue on separate page.)16. The following costs have been incurred by or on behalf of the minor and must be paid from the proceeds of the settlement: Your 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. (If additional space is needed, please continue on separate page.), one of the Justices of the17. The Department of Public Welfare, or any other entity, does (not) have a claim or lien against the plaintiff(s) as follows: Court in Witness, Honorableday of, 20 County, (If additional space is needed, please continue on separate page.)(Attorney must sign above and type name below)18. Counsel requests a fee in the sum of $ which is % per cent of the net settlement payable to the minor. A copy of the retainer agreement is attached.19. Counsel (has) (has not) and (will) (will not) receive collateral payments as counsel fees for representation involving the same matter from third parties (i.e. subrogation).Attorney(s) for20. The net settlement payable to the minor (after deduction of costs and attorney's fees) is $ .2 Phila. Civ.R. 2039.1(D)(3)(e) provides that if there is to be an allocation between parents and children or incapacitated personsor among children or other parties, the amounts allocated to each party and specific reasons for such allocation must be set forth. Additionally, if more than one plaintiff is involved, whether minor, adult or incapacitated, Petitioner must set forth the amount each is to receive and shall provide justification for the requested allocation. In the event a portion of the settlement is payable through the purchase of an annuity, set forth the credit rating of the entity which assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)WHEREFORE, Petitioner requests that he/she be permitted to enter into the settlement recited above and that the Court enter an Order of Distribution3 as follows:a.To $ Reimbursement for
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