Report Of Distribution {22.7}

PROBATE COURT OF________________ COUNTY, OHIO _____________, JUDGE IN THE MATTER OF________________________________________________ CASE NO.____________________ REPORT OF DISTRIBUTION Pursuant to the Entry filed on ________________________, ______, the proceeds have been paid as shown below and on the accompanying vouchers. Gross Proceeds Less: Medical expenses Reimbursement of suit expenses to _________ ______________________________________ Attorney fees to _________________________ Other: _________________________________ Total Net Proceeds Deposited pursuant to R.C. 2109.13 Form ____ attached Delivered to ___________________________ legal guardian of the estate Structured - see documents previously filed $ ___________________ $ ___________________ $ ___________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ Other:_____________________________________________________________. Balance _______________________ Attorney for Applicant Attorney Registration No.______________ $ ___________________ ____________________ Applicant ENTRY The above report of distribution is hereby approved. ____________________________ Date _______________________________ _______________, PROBATE JUDGE FORM 22.7 - REPORT OF DISTRIBUTION AND ENTRY Effective Date: January 1, 2015 American LegalNet, Inc. www.FormsWorkFlow.com