COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTYJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)FIRST JUDICIAL DISTRICTCIVIL TRIAL DIVISION:TERM, 20::No:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTIONSTO THE HONORABLE, THE JUDGES OF THE SAID COURT:THE PEOPLE OF THE STATE OF NEW YORK TOThe Petition of , Administrator/Executor of the Estate of , Deceased, by his attorney,, Esquire, respectfully requests:1. Petitioner is who was appointed Administrator/Executor of the Estate of , Deceased, on , 20, by the Register of Wills of County. A copy of the Decree of the Register is attached.GREETINGS:2. The plaintiff decedent died on as a result of: [set forth relevant information describing the underlying negligence or cause of action as required by Phila. Civ. R.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 room2206(D)] (If additional space is needed, please continue on separate sheet.)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.3. Notice of the institution of the action as required by Pa.R.C.P. 2205 and Phila. Civ. R. 2205 was given on to the following individuals:NAMEADDRESS, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(If additional space is needed, please continue on separate sheet.)(Attorney must sign above and type name below)4. Pursuant to Phila. Civ. R. 2206(B) Petitioner has served a copy of this Petition on the intestate heirs1 of plaintiff decedent (as provided in 20 Pa.C.S. §2101 et seq.) who are as follows: NAMEADDRESSRELATIONSHIPAttorney(s) for(If additional space is needed, please continue on separate sheet.)Office and P.O. Address1 In the event any court has appointed a guardian for a minor heir or incapacitated person, set forth the name of the guardian,Telephone No.: Facsimile No.: E-Mail Address:the Court date and manner of appointment.Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)5. Pursuant to Phila. Civ. R. 2206(B) Petitioner has served a copy of this Petition on the following parties who may have a possible interest: NAMERELATIONSHIPADDRESS6. Decedent (did) (did not) have a Will. A copy is attached. 7. The following unpaid claims2 have been raised and/or are outstanding in the decedent's estate:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CREDITORAMOUNT DUETHE PEOPLE OF THE STATE OF NEW YORK TO8. A Complaint was filed against defendant(s) as follows: .GREETINGS: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 of9. The following settlement has been proposed+: (If additional space is needed, please continue on a separate page.)o'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 room10. Counsel is of professional opinion that the proposed settlement is reasonable due to the following (state the reasons why in the professional opinion of counsel the settlement is proper):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 theCourt in Witness, Honorableday of, 20 County,11. Petitioner is of the opinion that the proposed settlement is reasonable. 12. 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.)(Attorney must sign above and type name below)13. Counsel requests counsel fees in the amount of $ which represents % of the net proceeds of the settlement.Attorney(s) forOffice and P.O. Address2 Petitioner must indicate whether the Department of Public Welfare has a claim or a lien against Petitioners, the Estate or anywrongful death beneficiaries. + In the event a portion of the settlement is payable through the purchase of an annuity, set forth the credit rating of the entity whichTelephone No.: Facsimile No.: E-Mail Address:assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments.Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)14. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorney's fees) as follows:a.Wrongful Death Claim$b.Survival Claim$. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TO15. The reason for the requested allocation are as follows: (If additional space is needed, please continue on a separate page.)GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable16. Pursuant to the Wrongful Death Statute (42 Pa.C.S. §8301), the beneficiaries of the Wrongful Death Claim, and the proportion of their interest, are as follows:,NAMEAMOUNT DUElocated 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
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