Fill and Sign the Ny Unified Court Form

Form WD-3 (4/98) SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF ______________________________ ___________________________________________________________________________________ In the Matter of the Application of as Administrat_______ of the Goods, Chattels and Credits which were of ACCOUNT ___________________________________________ Deceased. File # __________________ 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_________. ___________________________________________________________________________________ TO THE SURROGATE’S COURT: 1. I do render the following account of my proceedings as administrat_______of the goods, chattels and credits which were of ___________________________ , deceased, consisting of a claim against , who is insured by Insurance Company, for wrongful death arising on or about , as the result of an automobile accident involving the decedent and . 2. Letters of Administration of the goods, chattels and credits of the decedent were issued to me on ____________________, said letters being limited to the prosecution only, and not for the collection of any proceeds of, any action or claim for wrongful death. Simultaneously herewith, leave is being asked to compromise the claim for wrongful death of the decedent for the sum of $________________________. 3. There is submitted with this account my petition as administrat _______; and affidavit by , Esq., attorney for the petitioner herein; a copy of the paid funeral bill; and waivers of the necessary parties. 4. In view of the facts and circumstances, it is my opinion that a satisfactory result has been achieved through the efforts of my attorneys, and they are requesting disbursements in the sum of $ and that they receive thereafter a fee of % of the net proceeds. 5. The funeral bill in the sum of $ has been paid through no-fault insurance. 6. There are no outstanding hospital bills or doctors’ bills. 7. The only property coming into my hands is by reason of the compromise of the claim against the Insurance Company in the sum of $ . 8. The decedent left surviving no other next of kin except , his/her widow/widower, and ______________________________________________________________ _____________________________________________________________________________________, his/her children. All of the above persons are entitled to share in the proceeds of the compromise. (NOTE: WHERE THERE ARE NO DISTRIBUTEES UNDER A DISABILITY, THE RENDERING OF AN ACCOUNT IS USUALLY NOT REQUIRED.) (NOTE: REIMBURSEMENT OF FUNDS PAID FOR FUNERAL AND OTHER ADMINISTRATIVE EXPENSES, UNDER MOST CIRCUMSTANCES, ARE ALLOWABLE, AS ARE STATUTORY COMMISSIONS TO THE ADMINISTRAT(OR)(RIX). IF REIMBURSEMENT OR COMMISSIONS ARE NOT SOUGHT, THE PETITION SHOULD CONTAIN A WAIVER THEREOF). 9. There are no other claims or creditors of the estate that have been presented to or have come into my hands or knowledge except for the following: a) The Commissioner of Social Services has submitted a claim of $_______ for public assistance rendered to decedent and his/her family for the years _____ ________________. This claim was rejected. b) ______________________has submitted a claim for $__________ _________________ based on ______________________________ This claim was rejected. c) Decedent’s father/mother, ________________________________ has sought a share of the recovery based on an alleged pecuniary loss. This claim was rejected. 10. The following are the only persons interested in this proceeding: [List names of distributees, etc.] NAME RELATIONSHIP DATE OF BIRTH _____________________ _________________________ ________________________ _____________________ _________________________ ________________________ _____________________ _________________________ ________________________ _____________________ _________________________ ________________________ County Department of Social Services Possible Creditor New York State Tax Commission Possible Creditor _____________________ Attorneys _____________________ Defendant ________________________ Insurance Company Defendant’s Insurance Company 11. I charge myself as follows with the amount to be received on compromise of the claim for wrongful death against _________________ Insurance Company: $__ ______________ (Form WD-3) -2- 12. I credit myself as follows: a) With the amount to be paid to , Esqs., attorneys, including disbursements: $________________ b) With the amount to be paid to , widow/widower and distributee: ( %) $________________ c) With the amount to be paid to the guardian of the person and property of , infant, jointly with the Trust Officer of ______________ Bank ( %): $________________ d) with the amount to be paid to , son/daughter ( %): $________________ Total: $________________ Leaving no balance. Dated: ____________________ ______________________________ STATE OF NEW YORK COUNTY OF _________ss.: being duly sworn, deposes and says: That I am the administrat_________/accountant in the above estate, having been duly appointed by a decree of this Court. The foregoing account of proceedings contains to the best of my knowledge and belief a true and complete statement of my receipts and disbursements in the estate of ________________________________________ of all monies and other property belonging to the estate or fund which have come into my hands or which have been received by any person or persons by my order or authority for use since my appointment, and a full and true statement of account of the manner in which I have disposed of same and all property remaining in my hands at the present time, and a full and true account of the nature of each and every transaction may by me since my appointment. I do not know of any error or omission in said account to the prejudice of any person interested in said estate or fund. __________________________________ __________________________________ Sworn to before me this ______ day of . __________________________ Notary Public (Form WD-3) -3-