Fill and Sign the Expedited Petition to Approve Form

MC- 350EX FOR COURT USE ONLY CASE NUM BER: CASE NA ME: EXPEDITED PETITION TO APPROVE: Perso n With a Disability Minor Petitioner (name): Claimant (name): Address: Date of birth: Page 1 of 8 Form A dopted for Alternative Ma ndatory Use Judicia l Cou ncil of Cal ifornia MC-3 50EX [Ne w January 1, 2010] EXP EDI TED PETITI ON TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PEND ING ACTION OR DI SPOSITION OF PROCEEDS OF JUDGMENT FOR MI NOR OR PERSON WITH A DI SA BILI TY (Miscella neo us) FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF ATTO RNEY (Name, State Bar number, and ad dress): Cod e of Civil Pro cedure § 37 2 et seq.; Probate Code, § 3500 et seq.; Cal. Rules of Court, ru les 3.1384, 7.101, 7. 950, 7. 950.5, 7. 951 TELEPHONE NO.: E-M AIL ADD RESS (Option al): ATTO RNEY FOR (Name): STREE T ADDRE SS: MAILING ADDRE SS: CITY AND ZIP CODE: BRA NCH N AME: COMPROMISE OF DISPUTED CLAIM COMPROMISE OF PENDING ACTION DISPOSI TION OF PROCEEDS OF JUDGMENT 1. 2. a. b. No hearing date is re quested. HEA RING DATE : DEP T.: TIME: You must use this form if you wish to req uest exped ited cou rt approval of certain (1) compromises o f disputed claims o f a mi no r, (2) compromises of pendi ng actio ns or proceedi ngs i n wh ich a minor or a person with a d isabil ity (includi ng a con servatee) is a par ty, or (3) dispositions of the pr oceeds of judgments for a minor or person with a disabili ty. (See C ode Civ. Proc., § 3 72; Prob. Co de, § 3 500 et seq.) You may u se this form i f (1) you are re presented by an attorney; (2) the statements in item s 3a , 3b, 3c, 3 d, 3e , 3f , and either 3g(1) or 3g(2) below are true ; and (3) the court doe s not oth erwise order. If you qua lify and choo se to use this form, the co urt ma y c onside r and act o n you r petition without a he aring. If your comp romise or judg men t does not qu alify for ex pedi ted trea tment or you ch oose not to use this fo rm, you must use the Petiti on to Approve Compromi se of Disputed Claim or Pendi ng Acti on or Disposition of Proceeds of Judg me nt fo r Minor or Person With a Disabili ty (form MC -350), and the co urt will schedul e a he aring. See Cal . Rules of Co urt, rule s 7.950, 7.950.5 , and 7.951. 3. Exp edited pe titio n a. The judg men t for the claimant describe d in item 5c (exclusive of in terest a nd costs) or the total of the se ttlement descri bed in ite ms 12 and 13 payabl e to th e cla ima nt and all other persons named in ite m 13 is in the amount of $50,000 or less; or b. The settlement descri bed in item 12 repr esents p aymen t of the singl e-pe rson po licy l imi ts of all liabili ty insurance policies covering the d efendants n ame d in that i tem. T he inve stigation described in Attach ment 3 show s that all of those defend ants are judgmen t proof ou tside of thei r insu rance coverag e. (Descri be investi gation and results in c. No porti on of th e net proceed s of the j udg men t or settlement in favor of the clai man t is to be placed in a tru st. d. The clai man t's clai m or a ction is no t for damag es for the death of a person caused by the wrongful act or negl ect of anothe r. NOTICE TO PETITIONERS Petiti oner' s atto rney did not become involved with this matter, d irectly or i ndirectly , at the re quest of a party against whom the clai m is asserted or a party's insurance carrier. e. Petiti oner' s atto rney is not rep resenting, emplo yed by, or associated with a defen dant in this ma tter or an insurance carrier. (1) (2) Attac hment 3.) g. The re are no unresolve d di spute s concerni ng liens to be sati sfied from the proceeds of t he judg men t or settl eme nt. f. All defenda nts th at have app eared in a pendin g action on the claim a re pa rticipa ting in the propose d compromise or the cour t has fi nall y determined th at all settl ing parties ente red into the se ttle ment i n good faith. Age: Sex: c. d. e. Minor Person with a disabili ty f. CASE NAME: CASE NUMBER: Page 2 of 8 MC-350EX [New January 1, 2010] EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Relationship Petitioner's relationship to the claimant (check all applicable boxes): a. b. c. d. e. f. Parent Guardian ad litem Guardian Conservatorg. Disabled adult claimant is a petitioner. (See instructions for items 4e and 4f below.) Disabled adult claimant's express consen t to the relief requested in this petition is provided on Attachment 4f. Other relationship (specify): 4. 5. Nature of claim c. Case no.: Trial date:(Complete items 6–23.) (Attach a copy of the (proposed) judgment as Attachment 5c and complete items 14–23.) Name of court: Is not the subject of a pending action or proceeding. (Complete items 6–23.) Is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim. The claim of the minor or adu lt person with a disability: The judgment was filed on (date): is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against the defendants named below in the total amount (exclusive of interest and costs) of (specify): $ Defendants (names) : Additional defendants listed on Attachment 5. Nature of incident or accident The facts, events, and circumstance s of the incident or accident are (describe): Continued on Attachment 7. 7. Place: Persons involved (names): 6. Continued on Attachment 6. a. Date b. c. Incident or accident Th e incident or accident occurred as follows: Time: (If you checked item 4e or 4f, state fact s on Attachment 4e or 4f showing that the claimant has capacity under Probate Code section 812 to petition or consent to a petition. Only an adul t 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.) a. b. MC-350EX CASE NAME: CASE NUMBER: Page 3 of 8 MC-350EX [New January 1, 2010] EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Continued on Attachment 9. 9. Treatment The claimant received the following care and tr eatment for the injuries described in item 8 (describe): The claimant has not recovered complete ly from the effects of the injuries described in item 8, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): c. Continued on Attachment 10c. a. The claimant has not recovered complete ly from the effects of the injuries described in item 8, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries): b. Continued on Attachment 10b. 10. The claimant has recovered completely from the effects of the injuries described in item 8, and there are no permanent injuries. Extent of injuries and recovery 11. Petitioner has made a careful and diligent inquiry and investiga tion to ascertain the facts relating to the incident or accident in which the claimant was inju red; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner full y understands that if the compromise proposed in this petition is approved by the court and is consummated, th e claimant will be forever barred from seeking any further recovery of compensation from the settling defendants name d below even though the claimant's injuries may in the future appear to be more serious than they are now thought to be. Amount and terms of settlement By way of settlement, the defendants named below have of fered to pay the following sums to the claimant: Amounts Defendants (names) The terms of settlement are described on Attachment 12. (If the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.) 12. Additional defendants and amounts of fered are listed on Attachment 12. $ $ $ $ a. b. The total amount offered by all defendants named below is (specify): $ The defendants and amounts offe red by each are as follows (specify): c. Continued on Attachment 8. 8. Injuries The following injuries were sustained by the clai mant as a result of the incident or accident (describe): MC-350EX (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 10. A new report is not necessary so long as a previous report accurately describes the claimant's current condition.) CASE NAME: CASE NUMBER: Page 4 of 8 MC-350EX [New January 1, 2010] EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Settlement payments to others a. 13. No defendant named in item 12b has offered to pay money to any person or persons other than the claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. b. By way of settlement, one or more defendants named in item 12b have also offered to pay money to a person or persons other than claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. The total amount offered by all defendants to others (specify): $ Petitioner would receive money under the proposed settlement. (1) (2) Amounts Other plaintiffs or claimants (names) Additional plaintiffs or claimants and amounts are listed on Attachment 13.$ $ $ $ The settlement payments are to be apportioned and distributed as follows: (3) (4) The settlement payments are app ortioned between the claimant and each other plaintiff or claimant named above on a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other plaintiff or claimant are specified on Attachment 13. (5) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 13. The claimant's medical expenses, incl uding medical expenses paid by petitioner, Medicare, Medi-Cal, and private insurers, that are to be reimbursed from proceeds of settlement or judgment 14. (Identify each medical expense payer and the amount each paid, and explain any differences between items 14a(1), (4) and (5) in Attachment 14a.) c. (1) (2) Notice of this claim or action has been given to the St ate Director of Health Care Services under Welfare and (a) $ $ ( $ ( Total expenses: Total amount paid (including payments by privat e insurance, Medi-Cal, or Medicare): Total of negotiated reductions, if any: a. Totals Total amount of medical liens, if any: $ Total amount of medical expenses to be paid or reimbursed from proceeds: $ (1) (2) (3) (4) (5) None of the claimant's medical ex penses have been paid by Medi-Cal. Medi-Cal paid all or some or all of the claimant's medical expenses. (b) ) ) MC-350EX Institutions Code section 14124.73. A copy of the notice and proof of its delivery is attached. was filed in this matter on (date): In full satisfaction of its lien rights, M edi-Cal has agreed to accept reimbursement in the amount of: $ (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 14c(2).) b. (1) (2) None of the claimant's medical ex penses have been paid by Medicare. (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 14b(2).) Medicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights, Medicare will be reimbursed in the amount of $ d. The claimant's health plan is requesting re imbursement for medical expenses paid under the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ (Attach statements from the plan showing expense payments and requesting reimbursement.) e. Petitioner has paid claimant's medical expenses to be reimbursed in the amount of $ (See instructions for item 16.) Page 5 of 8 MC-350EX [New January 1, 2010] CASE NAME: CASE NUMBER: EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Items Payees (names) Amounts 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 or reimbursed out of claimant's share of the proceeds of the settlement or judgment: b. Continued on Attachment 15b. Total: $ $ $ $ $ $ $ $ $ $ $ $ $ 16. Reimbursement of expenses paid by petitioner Petitioner has paid none of the claim ant's expenses listed in items 14 and 15 for which reimbursement is requested. a. b. Petitioner has paid the following total amounts of the clai mant's expenses for which reimbursement is requested. (1) (2) (3) $ $ $ Total: $ Medical expenses listed in item 14: Attorney's fees included in the total fee amount shown in item 15a: Other expenses included in the total shown in item 15b: MC-350EX The claimant's attorney's fees and all other expenses (exc ept medical expenses), including fees or expenses paid by petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment 15. a.(If fees are requested, attach as Attachment 15a a declaration from the attor ney explaining the basis for the request, includin g a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attorney fee agreement in At tachment 15a.) Total amount of attorney's fees for whic h court approval is requested: $ c.Costs of suit attributable to mo re than one settling plaintiff are not apportioned between them on a pro rata basis based on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 15c. The claimant's medical expen ses, including medical expenses paid by pe titioner, Medicare, Medi-Cal, and private insurers, that are to be reimbursed from proceeds of settlement or judgment 14. g.(1) (2) Latest statements from all me dical service providers are attached as Attachment 14g. All medical expenses have been paid by private insurance, Medicare, or Medi-Cal. (Select (1) or (2) below.) f. There are one or more liens from medical service prov iders for payment of claimant's medical expenses. In full satisfaction of their lien claims, the lienh olders have agreed to accept the sum of: $ (Attach proofs of the expenses incurred and payments made, e.g., bills or invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) The balance of the proceeds of the proposed settlement or judgment remainin g for the claimant after payment or 17. $ Net balance of proceeds for the claimant reimbursement of all reque sted fees and expenses is (specify): Page 6 of 8 MC-350EX [New January 1, 2010] CASE NAME: CASE NUMBER: $ EXPEDITED PETITION TO APPROV E COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) The attorney has neither received nor expects to receive has received or expects to receive attorney's fees Amount Paid or Expected Date Paid or Expected From Whom Paid or Expected (name): Continued on Attachment 19b. b. $ $ $ $ $ $ $ or other compensation in addition to that requested in this pet ition for services provided in connection with the claim giving rise to this petition (if you answered ''has received or expects to receive,'' identify the person who paid or will pay the fees or other compensation, the amounts paid or to be paid, and the dates of payment or expected payment): 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: 20. There is a guardianship of the estate of the minor or a co nservatorship of the estate of the adult person with a a. (1) the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is specif ied in Attachment 20a(1). of the proceeds in money or othe r property will be paid or delivered to $ disability filed in (name of court): Case no.: (2) Petitioner is the guardian or cons ervator of the estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ property to be paid or delivered under 20a (1) 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 20a(2).of the money or other MC-350EX Total: $ a. Information about attorney representing or assisting petitioner 19. The attorney is not is representing or employed by any other party involved in this matter. (If you answered "is," identify the other party and explain the re lationship in Attachment 19a. If the other party is a defendant, you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1 and Cal. Rules of Court, rule 7.950.5(a)(6).) 18 .Summary Gross amount of proceeds of settlement or judgment for claimant: Expenses (other than medica l) to be paid from proceeds of settlement or judgment: Medical expenses to be paid from proceeds of settlement or judgment: Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): a. Attorney's fees to be paid from proceeds of settlement or judgment: e. b. c. d. ) f. $ $ ( $ Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): $ $ $ Page 7 of 8 MC-350EX [New January 1, 2010] CASE NAME: CASE NUMBER: EXPEDITED PETITION TO APPROV E COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) (4) conditions specified in Probate Code sections 3401–3402, without bond. T he name and address of the parent and the money or other property to be delivered are specified in Attachment 20b(4). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) will be paid or delivered to a parent of the minor, upon the terms and under the $ (3) withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified in Attachment 20b(3). $ of money will be invested in a singl e-premium deferred annuity, subject to 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) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability (2) institutions in this state, subject to withdrawal onl y upon the authorization of the court. The name, branch, and address of each depository are s pecified in Attachment 20b(2). $ of money will be deposited in insured accounts in one or more financial person so appointed. The money or other property are specified in Attachment 20b(1). will be appointed. $ of money and other property will be paid or delivered to the (5) Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are spec ified in Attachment 20b(5). will be transferred to a custodian for the benefit of the minor under the California $ is in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 20b(6). (Value must not exceed $20,000.) (6) of money will be held on such conditions as the court in its discretion determines $ 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: 20. (7) discretion determines is in the best in terest of the minor or the adult person with a disability. The proposed conditions and the property are specified in Attachment 20b(7). of property other than money will be held on such conditions as the court in its $ (8) will be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the cond itions specified in Probate Code section 3611(h). $ Continued on Attachment 20. (9) will be paid or transferred to the adult pers on with a disability. The money or other $ property is specified in Attachment 20b(9). MC-350EX (b) withdrawal only on order of the court. The terms and condit ions of the annuity are specified in Attachment 20a(3). will be transferred to a custodian fo r the benefit of the minor under the (c) will be invested in a single-premium deferred annuity subject to $ $ California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred ar e specified in Attachment 20a(3). will be deposited in insured accounts in one or more financial Petitioner proposes that a ll 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) (3) $ institutions in this state fr om which no withdrawals can be made without a court order. The name, branch, and address of each deposit ory are specified in Attachment 20a(3). There is a guardianship of the esta te of the minor or a conservatorship of the estate of the adult person with a disability a. CASE NAME: CASE NUMBER: Number of pages attached: Date: (TYPE OR PRINT NAME OF ATTORNEY) (SIGNATURE OF ATTORNEY) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: 23. (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) Page 8 of 8 MC-350EX [New January 1, 2010] EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Petitioner requests the following additional orders (specify and explain): Continued on Attachment 22. 22. Additional orders MC-350EX 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 compromi se settlement or proposed disposition and make such othe r and further orders as may be just and reasonable. 21.