Fill and Sign the Authority Settle Form

_____ JUDICIAL DISTRICT COURT FOR THE PARISH OF ____________________ STATE OF LOUISIANA NO. _________ DIVISION “_____” SECTION ________ IN RE: ________________ PETITION FOR AUTHORITY TO SETTLE MINOR’S CLAIM The petition of ____________ , a person of full age of majority, and a resident of the Parish of ____________ , State of Louisiana, with respect represents: 1. Petitioner, ____________ and his wife, ____________ (“the _________ s”), who have appeared herein as John and Jane Doe, were married in _________ , ____________ on _________ ___ , 20 ___ , which said marriage still exists, and petitioner and his wife live together in the bonds of matrimony, domiciled in the Parish of ____________ . 2. The _________ s adopted three children, including the minor ____________ , who resides with his parents in the Parish of ____________ . 3. At all relevant times, ____________ , ________________ , ____________ and ________________ were obligated to provide medical and mental health services to certain State employees, and ____________ was employed by ________________ and entitled to coverage for his minor children. 4. A number of disputes arose as to the payment of such benefits, and, as a result, a suit was filed under the caption “Jane and John Doe Individually and as administrator of the estates of Johnny and Charlie Doe v. _____________________________ , et al,” No. _________ on the docket of this court (“the suit”). While that litigation was in progress, ________________ and ________________ sought the protection of bankruptcy on _________ ___ , 20 ___ in the matter styled “In Re ________________ , et al,” Chapter 11 Case No. _________ , United States Bankruptcy Court for the _________ District of _________ . 5. The _________ s timely filed unsecured claims with the Bankruptcy Court, and the Debtors filed an objection to those claims. On or about _________ ___ , 20 ___ , the _________ s filed a response to those objections and, in order to resolve the claims, the Debtors and the _________ s reached a compromise which resulted in an allowed claim in the amount of $ _______ , which is expected to result in a distribution in the amount of approximately $ _______ , subject to attorney’s fees and costs, in exchange for which the captioned matter would be dismissed. 6. The primary basis of the lawsuit was claims for unpaid medical expenses, penalties and attorney’s fees. ____________ did not suffer any damages as a result of unpaid claims for medical benefits, because all medical expenses not paid by Defendants were paid out-of-pocket by ________________ including, but not limited to, the following amounts: 1) ________________ $ _______ 2) ________________ $ _______ 3) ________________ . $ _______ Total $ _________ The above amounts do not include penalties, attorney’s fees, damages, or interest. Nor do they include additional amounts paid by the _________ s for medical care for their children. 7. Given that the primary intent of the suit was to recover amounts due for unpaid medical expenses, as well as penalties and attorney’s fees for the failure to pay those amounts, and given that all of the medical care needed by _______ was paid for by ________________ and that ____________ was not denied any medical services, Petitioner, ____________ and the undertutrix, ____________ , aver that, in their opinion, an allocation to ____________ of the sum of $ _______ from the settlement is reasonable and just in the circumstances, and Petitioner desires to compromise any claim of ____________ on the settlement proceeds by payment to him of that amount, subject to attorney’s fees and costs. 8. Petitioner further avers that ____________ is suitable to be appointed under-tutrix ad hoc, against whom these proceedings may be presented contradictorily. WHEREFORE the foregoing considered, petitioner, ____________ , respectfully prays that ____________ be appointed under-tutrix ad hoc with whom these proceedings should be prosecuted contradictorily, and to assist petitioner to make the compromise hereinabove set forth, and that petitioner be authorized, empowered and instructed to enter into, make and consummate the proposed compromise and settlement as alleged and set forth in the above and foregoing petition, as concurred in and recommended by said under-tutrix ad hoc, under the terms of which, among other things, all Defendants are to be released, relieved, discharged and acquitted of and from any and all liability to the minor, ____________ , arising out of the acts alleged in the original and supplemental arid amending petitions filed in the suit, and the suit dismissed, with prejudice, each party to bear its own costs, in consideration of the payment of ________________ Dollars ($ _______ ), for and on behalf of the minor, ____________ , out of the gross settlement of approximately ________________ Dollars ($ _______ ) and ____________ is authorized to execute any arid all documents necessary to accomplish said settlement and distribution and to dismiss the suit on behalf of the minor, ____________ , and is further authorized to execute any other documents necessary for the ultimate consummation of the aforementioned compromise and settlement. Respectfully Submitted, ____________ ., LSBA # _______ ________________ ____________ , LA _______ ( ___ ) _______