Fill and Sign the New York Attorney Form

Form WD-4 4/98 SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF__________________________ -------------------------------------------------------------------------------X In the Matter of the Application of as Administrat_________of the Goods, Chattels and Credits which were of ATTORNEY’S AFFIDAVIT ___________________________________________ Deceased. File No.___________________ For leave to compromise a certain cause of action for wrongful death of the decedent and to render and have judicially settled an account of the proceedings as such Administrat . -------------------------------------------------------------------------------X STATE OF NEW YORK ) )ss.: COUNTY OF___________________) , being duly sworn, deposes and says: 1. I am a member of the firm of , Esqs., with offices at . 2. We were retained on , and filed a statement of retainer with the Office of Court Administration under Code Number . 3. After being retained by , widow/widower of decedent, an extensive investigation was conducted into the occurrence that resulted in the death of decedent, including obtaining police reports, hospital records, motor vehicle bureau records, etc. 4. It was ascertained that on at approximately a.m/p.m. of that day at [location] the decedent [describe details of accident] ______________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ The decedent sustained multiple injuries and was taken to Hospital, where he/she died at a.m./p.m. on without having regained consciousness. 5. Thereafter a claim was made against the Insurance Company, which insured the vehicle of . 6. The funeral and hospital bills were paid under no-fault benefits and none are left outstanding. 7. The insurance company of the defendant driver disclaimed any liability, claiming decedent [describe defendant’s defense] ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 8. After intensive negotiations with Insurance Company, it finally has made an offer in the sum of $ out of a total of $_____________ coverage for the wrongful death of decedent. 9. All of the proceeds of the settlement of the claim are to be allocated to the action for wrongful death, the decedent never having regained consciousness following the occurrence complained of. 10. That was, in addition thereto, appointed Guardian of the person and property of the infant, , by the Surrogate’s Court, County, on , under File No. . 11. In light of the fact that the owner of the vehicle involved in the accident alleges that the accident was the fault of the decedent and [provide other details] _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ your deponent submits that the settlement is fair and reasonable and should be accepted for the best interests of the estate. 12. Your deponent will prepare all papers necessary to accomplish said settlement and obtain approval of the Surrogate’s Court and do whatever is necessary on behalf of the estate and the next of kin. 13. The following expenses have been incurred [list all expenses]: Police reports $ ______________ Hospital records $_______________ Surrogate’s Court fees $ ______________ Motor Vehicle Bureau $ ______________ TOTAL $_______________ 14. Your deponent has not become concerned in this action at the request of the defendants or their attorneys or representatives, and no compensation has been or will be received by deponent from defendants or their attorneys or representatives. Any compensation to be received by way of fees herein is to be paid out of the proceeds of the proposed settlement and not otherwise. Your deponent has a written retainer with the administrat_______ herein providing for a fee of % of the net recovery, which your deponent submits is fair and reasonable in light of all of the facts and circumstances. Form WD-4 -2- 15. On , your deponent caused a check of the records of this court to be made for liens, assignments and encumbrances and found none, and your deponent has been advised by petitioner that petitioner does not know of any filed or recorded, and your deponent has inquired of the petitioner and is satisfied that the only claims that have been filed with the administrat______ are those shown in the petition. Your deponent waives notice and the requirement that any security be filed and consents to the entry of a decree without any further notice. 16. No previous application for the relief requested herein has been made to any court or judge. 17. Your deponent requests that a fair and reasonable sum for services rendered and to be rendered be allowed in the sum of $ , together with disbursements in the sum of $ . WHEREFORE, deponent respectfully prays that the relief requested herein be granted. ____________________________________ Sworn to before me this day of , 20 . ________________________________ Notary Public Form WD-4 -3-