Report Of Distribution Of Wrongful Death And Survival Claims {14.3}

<document>COURT COUNTY OFPROBATE COURT OF COUNTY, OHIOERIE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.ESTATE OF , DECEASED CASE NO. Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMSPursuant to Entry filed,,the proceeds have been paid as shown below andon the accompanying vouchers. Gross Proceeds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$Funeral and burial expenses$THE PEOPLE OF THE STATE OF NEW YORK TOFiduciary fees to$Reimbursement of case expenses to$Attorney fees to$GREETINGS:Survival claim to the estate$WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Total Deductions$located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomNet Proceeds$Net proceeds to beneficiaries: To:$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 $50 and all damages sustained as a result of your failure to comply.To:$To:$, one of the Justices of theTo:$Court in Witness, Honorableday of, 20 County,To:$To:$(Attorney must sign above and type name below)To:$Total payments to beneficiaries$Attorney(s) for0.00BalanceOffice and P.O. AddressThe fiduciary states that there are no other assets remaining in the estate. The fiduciary states that there are assets remaining in the estate.Telephone No.: Facsimile No.: E-Mail Address:Attorney for FiduciaryFiduciaryAttorney Registration No.Mobile Tel. No.:4/97FORM 14.3 REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMSAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.ENTRYJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)The above report of the distribution of the proceeds is hereby approved.There being no further assets to administer, the fiduciary and surety, if any, are discharged.DatePROBATE JUDGE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com</document>