Fill and Sign the Doubtful Claim Form

IN THE CHANCERY COURT OF       COUNTY, MISSISSIPPI IN THE MATTER OF THE DOUBTFUL CLAIM OF       , A MINOR PETITION TO SETTLE DOUBTFUL CLAIM Comes now       , a minor, by and through his/her next friends and parents,       and       , and respectfully petitions this Court for authority to compromise and settle the unliquidated claim of       for damages arising as a result of injury which he/she sustained on or about             ,       , and in support thereof would show unto the Court the following: 1. That       is       years of age, date of birth being             ,       . Petitioners would show that on or about             ,       , that the minor child was enrolled in day care at       , owned by       in       , Mississippi. That when said child was picked up at       in the       , the director and owner,       , admitted that the minor child,       , had been bitten by said director on the       , in an attempt to demonstrate to him/her not to bite other children. 2. Petitioners would show that the bite sustained by the minor child was of sufficient force that said child sustained teeth marks and discoloration and a bruising condition to said area. Petitioners would further show that medical care was not required for said child, and that the injured area has healed and that there are no physical residuary effects of said bite. 3. Without admission of any liability, as a complete accord and satisfaction of disputed claims and a final settlement of all claims, petitioners have agreed to accept, and the owner,       , has agreed to pay $       for all damages arising as a result of the injuries sustained by       while in his/her day care, and do further pay additional attorney fees in the amount of $       . 4. That the proposed settlement is a fair and reasonable settlement of the claims, and that the petitioners herein should be authorized to execute and deliver a good, valid and binding release, fully acquitting and discharging       , and       and any and all other persons employed therewith from any and all further known or unknown liability, arising from the injuries sustained by       as a result of the above - stated injury. WHEREFORE, PREMISES CONSIDERED, petitioners herein respectfully request the Court for authority to conclude the settlement of this claim in the total sum of $       , plus additional attorney fees in the amount of $       , and that upon a final hearing, and after the evidence taken, that the Court will approve and authorize settlement and will further authorize the petitioners herein to execute a release of all claims. PETITIONERS PRAY FOR GENERAL RELIEF! Respectfully submitted,