Fill and Sign the Order Approving Third Party Settlement Form

IN THE CIRCUIT COURT OF COUNTY, MISSISSIPPI VS. CIVIL ACTION NO. ORDER APPROVING THIRD-PARTY SETTLEMENT Came on this day to be heard on the Motion for Approval of Third-Party Settlement filed herein by , Plaintiff, and the Court being fully advised in the premises, finds as follows: 1. That is the Plaintiff in the above-styled and numbered civil Action and is an adult resident citizen of County, Mississippi. 2. That the claim of as set forth in the above-styled and numbered civi l action is a doubtful claim and it is not one readily collectible in that liabil ity is not certain and in that     has denied liability for the injuries and damages sustained by . Furthermore, an Orde r Granting Motion for Summary Judgment and Final Judgment of Dismissal With Prejudice was entered by this Court on , awarding summary judgment to the De fendant    and dismissing the lawsuit with prejudice. However, has offered to settle and compromise this civil action and the claims of for the total sum of $ . 3. That at the time of the accident in question, was employed as a patrolman by the City of , Mississippi. Since said accident, the City of , Mississi ppi and its workers' compensation insurance carrier, , have paid medical benefits for the benefit of     in the amount of $ and have paid workers' compensation temporary total disability benefits to in the amount of $ . is entitled by law to ful l reimbursement for all medical and compensation heretofore paid to or on behalf of ; however, ha s agreed to waive its entire workers' compensation lien and all claims for reimbursement it may have arising from said medical and compensation benefits as a condition of this proposed settlement. 4. That the aforesaid settlement and compromise is a fair and reasonable settl ement of the doubtful claims of , and it is in the best interest of , tha t said sum be accepted and settlement be made and consummated and , be authorized to join with in the execution of appropriate releases. 5. That has engaged the services of , attorney at law, and said attorney has rendered valuable services on behalf of and said attorney is entitled t o a reasonable fee to be paid out of the proceeds of said settlement. IT IS, THEREFORE, ORDERED AND ADJUDGED that be, and he is hereby, authorized and directed to compromise and settle the claim of against for the total sum of $ ; IT IS FURTHER ORDERED AND ADJUDGED that be, and it is hereby, authorized and directed to waive its entire workers' compensation lien and all c laims for reimbursement it may have for medical and compensation benefits paid to and on behal f of   ; IT IS FURTHER ORDERED AND ADJUDGED that and be, and they are hereby, authorized and directed to execute and deliver the appropriate releases to and    is further authorized and directed to withdraw and dismiss the appeal and Notice of Appe al filed in this civil action; SO ORDERED this the day of , . ___________________________________ CIRCUIT JUDGE AGREED TO AND APPROVED BY: _____________________________________ HIS ATTORNEY BY:__________________________________ ITS ATTORNEY BY:__________________________________ ITS ATTORNEY