Fill and Sign the Ny Waiver Consent Form

Form WD-6 (Waiver and Consent for Individual) SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of the Application of as WAIVER AND CONSENT Administrat of the Goods, Chattels and Credits which were of , deceased, for leave to compromise a certain cause of action FILE # ________________ for wrongful death of the decedent and to render and (as of 9/87) have judicially settled an account of the proceedings as such Administrat . TO THE SURROGATE’S COURT: The undersigned, being over the age of 21 years, having been born on and residing at being a person interested as (state relationship) of decedent, hereby appears and waives the issuance and service of a citation in the above proceeding and consents to the following relief: ( The adult distributee, or other adult interested party, must specifically consent to each and every item of relief requested by the petitioner) NOTE: If the adult distributee is entitled to share in the proceeds of the settlement, but is voluntarily relinquishing that right, this must be clearly stated as well. THAT the account of the proceedings of , as administrat of the estate of , deceased, a copy of which is attached, should be judicially settled, and THAT the administrat should be empowered to compromise and settle a certain claim for the wrongful death against for the sum of $ and to discontinue any claim for conscious pain and suffering, and THAT the provisions of the limited Letters of administration issued to the petitioner on restraining the compromise or collecting upon the aforesaid claim and cause of action should be modified to permit said compromise, and THAT the filing of a bond should be dispensed with, and THAT the defendant, , or defendant’s insurance company should pay to , Esqs., out of the proceeds of the settlement for the claim for 1 wrongful death, the sum of $ As and for attorneys’ fees together with disbursements in the sum of $ , and THAT the entire recovery of $ should be allocated to the cause of action for decedent’s wrongful death, and THAT the balance of the settlement, to wit the sum of $ , should be distributed to those distributees having sustained a pecuniary loss as follows: % of the balance to widow/widower of decedent; % of the balance to , child of decedent; % of the balance to , child of decedent, and THAT the claim of should be rejected, as a non distributee, and THAT the claim of in the amount of $ should be rejected, and THAT upon payments as hereinbefore mentioned, the said administrat should be permitted to execute and deliver general releases and all other necessary papers to the defendant or defendant’s insurance company, releasing them from all claims against them arising out of the aforesaid action for wrongful death, together with any other papers necessary to effectuate the said compromise, and THAT the entire settlement be considered as a settlement for a cause of action for wrongful death and a waiver of my right to receive any distributee share of the settlement. DATED: _____________________ STATE OF NEW YORK ) COUNTY OF )ss: On the __________ day of __________________________, 20____, before me personally came known to me to be the person who is described in the foregoing Waiver and Consent, and acknowledged to me that he/she executed same. Notary Public Commission Expires: (Affix Stamp) 2