Fill and Sign the Ny Unified Court 497321965 Form

Form WD-7 (as of 4/98) At a Surrogate’s Court held in and for the County of _________ , at the Courthouse in _______, New York, on the _______ day of ____________________, 20____. P R E S E N T: HON.______________________ _______________County Surrogate ----------------------------------------------------------------------X In the Matter of the Application of ___________________________________as DECREE Administrat___________of the Goods, Chattels and Credits which were of Administrat___________, deceased, for leave to compromise and settle the claim and cause of action arising out of the death of the FILE # ________________ decedent and to judicially settle his/her account relating to the proceeds thereof -----------------------------------------------------------------------X Upon the Petition of , as Administrat_______ of the Estate of , deceased, duly verified the day of , 20 , in which application was made for an Order permitting the said , as Administrat_____to compromise and settle for the sum of $ the cause of action against___________________________ for the wrongful death of the decedent, . And to discontinue the action for conscious pain and suffering and to discharge and release said defendant and insurance company from all suits and claims upon the payment of the said $ in settlement of the cause of action herein, And that the entire recovery of said action should be allocated to the cause of action for decedent’s wrongful death, to modify the Letters of Administration to permit said compromise, dispense with the filing of a bond, judicially settle the account, pay to , Esqs., their fee for services rendered, reject the claim of the Department of Social Services, and reject the claims of and , And more than seven months having elapsed since the granting of Letters of Administration to , and the Surrogate having issued a Citation to all persons interested in the estate of said deceased to attend such judicial settlement on the day of , 20 , at_______a.m., at the Surrogate’s Court,________________County, And the said Citation having been duly returned with proof of due service thereof, or the due appearance and waiver of notice, by the following named person or corporations, to wit: [List names of distributees, and, if applicable,__________County Department of Social Services, New York State Tax Commission, Defendant, and Defendant’s Insurance Company] And the said , petitioner herein, having appeared by his/her attorney, And the said having appeared by , his/her attorneys, and having filed objections to said account, And said________County Department of Social Services having appeared by_________ _________________________, its attorney, and having filed objections to said account, And said New York State Tax Commission having appeared by , its attorney, and having filed objections to said account, And the Court having appointed , as Guardian Ad Litem for , And having filed objections on behalf of his/her ward, , And having filed a report as such guardian, And a hearing having been held, and the Court having rendered a decision dated _______ ________________, granting the petition to compromise the cause of action for wrongful death and to judicially settle the account, And the Court having examined the said account and having found the state and condition of said account to be as set forth in the following statement recorded with the Court: SUMMARY STATEMENT OF THE SETTLEMENT PROCEEDS The Administrat_____is charged with $____________________ the proceeds of the action of wrongful death to be distributed. TOTAL CHARGES $ _______________ The Administrat______is credited with $ ___________________ the following amounts TOTAL CREDITS $ _______________ BALANCE OF THE SETTLEMENT PROCEEDS TO BE DISTRIBUTED $ _______________ And it appearing the said Administrat________has fully accounted for all monies and properties of the estate in said summary statement, and the Administrat_____having waived any claim to statutory commissions, it is hereby ORDERED, ADJUDGED AND DECREED that the petitioner’s application for leave to compromise and settle the cause of action for wrongful death and to allocate the entire amount of the proceeds to the cause of action for wrongful death and to grant leave to discontinue the cause of action for conscious pain and suffering is granted; and it is further ORDERED, ADJUDGED AND DECREED that the petitioner as Administrat____of the decedent’s estate is authorized to settle and discontinue the claims and causes of action for conscious pain and suffering and wrongful death against the defendant, , and petitioner is authorized to deliver general releases and discontinuances and any other papers or documents that may be required to effectuate a settlement and discontinuances or withdrawals of the said claims and causes of actions for conscious pain and suffering and wrongful death; and it is further ORDERED, ADJUDGED AND DECREED that the entire settlement sum of $ ________ is allocated to the cause of action for wrongful death, and the personal injury action is discontinued with prejudice and without interest, costs or disbursements; and it is further ORDERED, ADJUDGED AND DECREED that the entire settlement sum of $ ________ be paid by the defendant, or defendant’s insurance company as follows: To as fee for services as Guardian Ad Litem $ ______________ To as fee for services as attorney for the Administrat________ herein $ ______________ To in reimbursement of disbursements as attorney for the Administrat _____ herein $ ______________ To as and for his/her share as surviving spouse and beneficiary of said decedent pursuant to EPTL section 5-4.4, equal to % $ ______________ To , child and next of kin by payment to , Guardian of the property of , jointly with the Trust Officer of the Bank, as and for his/her share as next of kin of said decedent pursuant to EPTL section 5-4.4, equal to % $ ______________ and it is further ORDERED, ADJUDGED AND DECREED that the claims of the Department of Social Services, the New York State Tax Commission, and ___________________________________ hereby are disallowed and objections filed by these parties are dismissed; and it is further ORDERED, ADJUDGED AND DECREED that upon the defendant; or the defendant’s insurance company, making payments as aforesaid, , as Administrat_______of the estate of , deceased, be and hereby is discharged from any and all further liability as to all matters and things embraced in the aforesaid account and determined by this decree; and it is further ORDERED, ADJUDGED AND DECREED that the giving of a bond or other security in connections therewith be dispensed with, and that the restrictions on the Letters of Administration be modified to allow the above settlement; and it is further ORDERED, ADJUDGED AND DECREED that the account of ____________________ as Administrat_______is hereby judicially settled. ENTER: ___________________________ DATED:___________________________ ______________________________ Surrogate NOTICE OF ENTRY ________________________________________ ___________________, Chief Clerk ___________________County Surrogate’s Court