Fill and Sign the Approve Claim Ca Form

––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– –– –– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– –– –– ––––– –– –– –– –– –– –– –– –– –– –– MC-350 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) FOR COURT USE ONLY TELEPHONE NO. FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name) : SUPERIOR COURT OF CALIFORNIA, COUNTY OF CITY AND ZIP CODE BRANCH NAME CASE NAME: CASE NUMBER PETITION TO APPROVE: HEARING DATE COMPROMISE OF DISPUTED CLAIM COMPROMISE OF PENDING ACTION DISPOSITION OF PROCEEDS OF JUDGMENT DEP T. TI ME Minor Adult Person With A Disability NOTE : This form is to be used for the compromise of a disputed claim of a minor, the compromise of a pending action or proceeding in which a minor or an adult person with a disability (including a conservatee) is a party, or disposition of the proceeds of a judgment for a minor or adult person with a disability under Code of Civil Procedure section 372 et seq. or Probate Code section 3500 et seq. The person compromising the claim or the action and the minor or adult person with a disability must attend the hearing on this petition unless the court for good cause dispenses with the personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment, and hospitalization. 1 Petitioner (name): 2 Claimant (nam e): Addres s: b. Date of birth: c. Age: d. Sex: e . Min or Adult person with a disability 3. Relationship a. Petitioner's relationship to the claimant (check all applicable boxes): ( 1 ) Pare nt ( 7 ) Other relationship (specify:) ( 2 ) Guardian ad litern ( 3 ) Guardi an ( 4 ) Conservat or ( 5 )( 6 ) Disabled adult claimant is a petitioner. (See instructions f oritems 3a(5) and (6) below.) Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3a(6). (If you checked item (5) or (6), state facts on Attachment 3a(5) or (6) showing that the claimant has capacity under Probate Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.) b. (1) Petitioner is not is a plaintiff in a suit arising out of the same incident or accident from which the claim arises. (if you answered ''is,'' explain in Attachment 3 b the circumstances and whether the petitioner's own claim or its disposition has in any way affected the proposed compromise of the claim that is the subject of this petition.) ( 2 ) The claim that is the subject of this petition has been reduced to a judgment for the claimant. c. Petitioner is not is a claimant against the recovery of the claimant. (If you answered “is”, explain in Attachment 3c the circumstances and whether the petitioner's own claim or its disposition has in any way affected the proposed compromise of the claim or the proposed disposition of the proceeds of the judgment that is the subject of this petition.) Page 1 of 8 Form Adopted for Mandatory Use Judicial Council of California MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR Code of Civil Procedure § 372 et seq., Probate Code, § 3500 et seq. ,PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT Cal. Rules of Court, rules 3.1384, 7.950, 7.951 FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) 7.9 54electronic form ã 2005- 7 WWW.LawCA.com Law Publishers ––––– ––––– –– –– ––––– ––––– ––––– –– ––––– ––––– –– ––––– ––––– ––––– –– –– ––––– –– ––––– –– ––––– ––CASE NAME: CASE NUMBER 4. Nature of The claim of the minor or adult person with a disability a . has not been filed in an action or proceeding. (Complete items 5-23.) b . is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim. Name of court: Case No.: Trial date: (Complete items 5- 23.) c . Amount: $has been or will be reduced to a judgment for the claimant after a trial on the merits of the claim. Judgment filed on (date): (Attach a copy of the (proposed) judgment as Attachment 4c and complete items 7-8, 10-11, 14-20, and 22-23.) 5 . Incident or accident The incident or accident occurred as follows: a. Date and time b. Place: c. Persons involved (names): Continued on Attachment 5. 6 . Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe): Continued on Attachment 6. 7. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Continued on Attachment 7. 8. Treatment The claimant received the following care and treatment for the injuries sustained as a result of the incident or accident (describe): Continued on Attachment 8 MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 2 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350 ––––– ––––– –– –– –– ––––– –– –– ––––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––CASE NAME: CASE NUMBER 9 . injuries and recoveryExtent of (An original or a photocopy of all doctors' reports containing a diagnosis of and prognosis for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 9.) a . The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent injuries. b . The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries): Continued on Attachment 9b. c . The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): Continued on Attachment 9c. 10. Medical expenses a. Totals (1) Total charges: (2) Total amount paid (whether or not by (3) Total of negotiated reductions, (4) Total net amount (5) Total amount of medical $ $ $ $ $ (6) Total amount of medical expenses to be paid from proceeds of settlement or judgment: $ (Explain any differences between items 10a (4),(5), and (6) in Attachment 10) b. The names of the hospitals, doctors, and other health-care providers that have furnished care and treatment for claimant, the respective charges for such care and treatment, the amounts paid, the amounts of negotiated reductions of the charges, if any, the net amounts owed to each provider, and the amount of the provider's lien, if any are described below: (1) (a) Provider (name): (b) Address: (c) Care or treatment (describe): (d) Amount charged: (e) Amount paid (whether or not by insurance): (f) Negotiated reduction, if any: (9) Net amount owed: (h) Amount of lien, if any: $ $ $ $ $ (i) Amount to be paid from proceeds of settlement or judgment: $ (2) (a) Provider (name): (b) Address: (c) Care or treatment (describe): (d) Amount charged: (e) Amount paid (whether or not by insurance): (f) Negotiated reduction, if any: (g) Net amount owed: (h) Amount of lien, if any: $ $ $ $ $ (i) Amount to be paid from proceeds of settlement or judgment: $ Continued on Attachment 10. (Provide information about additional providers in the above format.) MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 3 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350 ––––– ––––– –– –– ––––– ––––– ––––– ––––– –– –– –– –– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– –– ––––– ––CASE NAME: CASE NUMBER 1 1. Information about attorney representing or assisting petitioner a. (1) Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the claim asserted (If this item is checked, go to item 12) . ( 2 ) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim asserted (if this item is checked, answer questions 11b-11g below) . b. The attorney who has represented or assisted petitioner is (name): (1) State Bar number: (2) Law firm (3) Address (4) Telephone number: c. The attorney did not did become concerned with this matter, directly or indirectly, at the instance of a party against whom the claim is asserted or a party's insurance carrier. (If you answered ''did,'' explain the circumstances in Attachment 11c.) d. The attorney is not is representing or employed by any other party or any insurance carrier involved in the matter. (If you answered “is”, identify the party or carrier and explain the relationship in Attachment 11d.) e. The attorney has not has received attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition (if you answered “has”, identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment) : From whom (names) Amount s Dat es $ $ $ Continued on Attachment 1 1 e. f. The attorney does not does expect to receive attorney fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition (if you answered “does”, identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment) : From whom (names) Amount s Expected dates $ $ $ Continued on Attachment 11f. g. Petitioner and the attorney do not do have an agreement for services provided in connection with the claim giving rise to this petition. (If you answered “do”, describe the terms of the agreement including the amount of any contingency fee): Continued on Attachment 11 g MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 4 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350 ––––– ––––– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– –– –– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –––––CASE NAME: CASE NUMBER 1 2 . Amount and terms of settlement a . Amount sBy way of settlement, the following defendants have offered to pay the following sums to the claimant: Defendants (names) $ $ $ Total: $ Continued on Attachment 12. b. The terms of settlement are as follows (if the settlement is to be pald in installments, both the total amount and the present value of the settlement must be included): Continued on Attachment 12. 1 3 . Damage payments to others a . By way of settlement, no defendant has offered to pay to any other person or persons money damages arising out of the same incident or accident that resulted in injury to the claimant. b . By way of settlement, one or more defendants have offered to pay to another person or persons money damages arising out of the same incident or accident. (1) The total amount offered by all defendants to others (specify) : $ (2) The damage payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amount s $ $ $ Continued on Attachment 13b 14. Attorney fees and expenses (other than medical expenses) to be paid from proceeds of settlement or judgment a. Total amount of attorney fees for which court approval is requested: $ (If attorney fees are requested, a declaration from the attorney explaining the basis for the requested fees must be attached as Attachment 14a.) b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment: Item s Payees (names) Amount s $ $ $ $ $ $ $ $ $ $ $ Continued on Attachment 14b. Total: $ MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 5 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350 ––––– ––––– ––––– –– ––––– –– ––––– –– ––––– –– –– ––––– –– ––––– –– ––––– –– ––––– –– –– ––––– –– –– ––––– –– ––––– –– –––––CASE NAME: CASE NUMBER 15. Total balance The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment of aII requested fees and expenses is: $ 16. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows: a . There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability filed in (name of court): Case No.: ( 1 ) $ of the proceeds in money or other property will be paid or delivered to the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is specified in Attachment 16a(l). ( 2 ) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. of the money or otherPetitioner requests authority to deposit or invest $ property to be paid or delivered under 16a(l) with one or more financial institutions in this state or with a trust company, subject to withdrawal only as authorized by the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 16a(2 ). ( 3 ) Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply): ( a ) $ will be deposited in insured accounts in one or more financial institutions in this state from which no withdrawals can be made without a court order. The name, branch, and address of each depository are specified in Attachment 16a(3). ( b ) $ will be invested in a single-premium deferred annuity subject to withdrawal only on order of the court. The terms and conditions of the annuity are specified in Attachment 16a(3). ( c ) $ will be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are specified in Attachment 16a(3). ( d ) $ will be transferred to the trustee of a trust that is either created by or approved of in the order approving the settlement or the judgment given or to be given for the minor. This trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 16a(3) A copy of the (proposed) judgment is attached as Attachment 4c. ( e ) $ will be transferred to the trustee of a special needs trust under Probate Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the property to be transferred are specified in Attachment 16a(3). b . There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability. Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check all that apply): ( 1 ) will be appointed. $A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability of money and other property will be paid or delivered to the person so appointed. The money or other property are specified in Attachment 16b(l). ( 2 ) $ of money will be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only upon the authorization of the court. The name, branch, and address of each depository are specified in Attachment 16b(2). ( 3 ) $ of money will be invested in a single-premium deferred annuity, subject to withdrawal only upon the authorization of the court The terms and conditions of the annuity are specified in Attachment 16b(3) MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 6 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350 ––––– ––––– –– ––––– –– ––––– –– ––––– –– ––––– –– –– ––––– –– ––––– –– ––––– –– ––––– –– –– –– ––––– –– –– ––––– ––CASE NAME: CASE NUMBER 1 6 . b Disposition of proceeds of settlement or judgment ( 4 ) $ will be paid or transferred to the trustee of a special needs trust under Probate Code sections 3604 and 3611(c) for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the money or other property to be paid or transferred are specified in Attachment 16b(4). ( 5 ) $ will be paid or delivered to a parent of the minor, upon the terms and under the conditions specified in Probate Code sections 3401-3403, without bond. The name and address of the parent and the money or other property to be delivered are specified in Attachment 16b(5). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) ( 6 ) $ will be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 16b(6). ( 7 ) $ will be transferred to the trustee of a trust that is either created by or approved of in the order approving the settlement or the judgment given or to be given for the minor. This trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 16b(7). A copy of the (proposed) judgment is attached as Attachment 4c. ( 8 ) $ of money will be held on such conditions as the court in its discretion determines is in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 16b(8). (Value must not exceed $20,000.) ( 9 ) $ of property other than money will be held on such conditions as the court in its discretion determines is in the best interest of the minor or the adult person with a disability. The proposed conditions and the property are specified in Attachment 16b(9). (1 0) $ will be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specified in Probate Code section 361 1 (h). (1 1) $ will be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 16b(11). Continued on Attachment 16. 17. Medi- Cal Notice of the claim or action h a s has not been given under Welfare and Institutions Code section 14124.73. (If notice has not been given, explain) : Continued on Attachment 17 1 8 . Statutor y fliens or special needs trust Petitioner requests a court order for payment of funds to a special needs trust (explain how statutory liens under Probate Code section 3604, if any, will be satisfied) : Continued on Attachment 18. MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 7 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350 ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– –– –– ––––– ––––– ––––– ––––– –––––CASE NAME: CASE NUMBER 19. Summary a. Gross amount of proceeds of settlement or judgment for claimant: $ b. Medical expenses to be paid from proceeds of settlement or judgment: $ c. Attorney fees to be paid from proceeds of settlement or judgmen t: $ d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ e. Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)) : $ ( ) f. Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): $ 2 0 . Additional orders Petitioner requests the following additional orders (specify and explain): Continued on Attachment 20 2 1 . Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner fully understands that if the compromise proposed in this petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further recovery of compensation even though the claimant's injuries may in the future appear to be more serious than they are now thought to be. 22. Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise settlement or proposed disposition and make such other and further orders as may be just and reasonable. 23. Number of pages attached: Dat e: (SIGNATURE OF ATTORNEY)(TYPE OR PRINT NAME OF ATTORNEY) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dat e: (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) MC-350 [Rev. January 1, 2007] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING Page 8 of 8 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR ADULT PERSON WITH A DISABILITY (Miscellaneous) MC-350