COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGECalendar No.ESTATE OF, DECEASED CASE NO. JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS [R.C. 2117.05, 2125.02, 2125.03, Civ. R. 19.1 and Sup. R. 70] The fiduciary states: (Check whichever of the following are applicable, strike inapplicable words, and incorporate all attachments into a single statement.) . There is an offer of (full) (partial) settlement without suit being filed. . There is an offer of (full) (partial) settlement after suit was filed. The style of the case, the court and the case number being . . A judgment has been recovered for damages for decedent's wrongful death (and personal injury and property damage arising out of the same act and which survive the decedent). . The amount of the settlement or judgment is $. . This is a partial settlement and therefore the estate must remain open pending final disposition of the claims. . The offer includes, or the judgment sets forth separately, reasonable funeral and burial expenses in the amount of $. . Reasonable compensation for the fiduciary's services is $ and an itemization of such services is attached. . A reasonable attorney fee for the attorney's services is $ and reimbursement to the attorney for case expenses is $. A copy of the attorney's fee contract that (has) (has not) received prior approval of this Court, subject to modification, and an itemization of case expenses are attached. . The net proceeds of $ should be allocated, $ to the wrongful death action and $ to the survival action. A statement in support thereof is attached. . A statement in support of the proffered settlement is attached. . Supplemental forms required by local rule of court are attached. . All of the beneficiaries of the wrongful death action are on an equal degree of consanguinity, are adults, and have agreed how the net proceeds are to be distributed. . The beneficiaries of the wrongful death action are not on an equal degree of consanguinity, or one or more of the beneficiaries is a minor, or the beneficiaries have not agreed how the net proceeds are to be distributed.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE 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:«xe25/1'-Mobile Tel. No.:PAGE 1 OF FORM 14.0 APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMSAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.CASE NO. Calendar No.. The surviving spouse, children, and parents of the decedent and other next of kin who have suffered damages by reason of the wrongful death are as follows and the distribution should be as follows: NameJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)ResidenceRelationshipBirthdateAmount Addressto Decedentof Minor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TO. The survival claim beneficiaries are as follows: NameResidenceRelationshipBirthdate AddressGREETINGS:to Decedentof MinorWE 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.The fiduciary requests that the Court approve the application and authorize the fiduciary to execute a (complete) (partial) release, which upon payment of the settlement shall be a (complete) (partial) discharge of the claim., one of the Justices of theCourt in Witness, Honorableday of, 20 County,Attorney for FiduciaryFiduciary(Attorney must sign above and type name below)Attorney Registration No.«ftiI-Attorney(s) forENTRY SETTING HEARING AND ORDERING NOTICEThe Court sets at o'clock .M. as the date and time for hearing the above application and orders notice to be given by the fiduciary, as provided in the Rules of Civil Procedure, to the wrongful death and survival claim beneficiaries who have not waived notice.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Judge Jack R. PuffenbergerMobile Tel. No.:PAGE 2 OF FORM 14.0 APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMSAmerican LegalNet, Inc. www.USCourtForms.com
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