Petition for Authority to Settle Doubtful Claim

         , A MINOR

__________________________________

         ,

INDIVIDUALLY AND AS MOTHER

AND NEXT FRIEND OF

__________________________________

         ,

INDIVIDUALLY AND AS FATHER OF

_________________________

ATTORNEY AT LAW

STATE OF MISSISSIPPI

COUNTY OF

Personally appeared before me, the undersigned authority in and for the aforesaid state and county, the within named , Petitioner, who acknowledges that he/she signed and delivered the above and foregoing Petition for Authority to Settle Doubtful Claim and Joinder, individually and as mother and next friend of , on the day and year therein mentioned as his/her voluntary act and deed, and that the matters and facts set forth therein are true and correct as stated.

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GIVEN UNDER MY HAND AND OFFICIAL SEAL, on this the day of , 20.

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NOTARY PUBLIC

My Commission Expires:

IN THE CHANCERY COURT OF THE JUDICIAL DISTRICT

OF COUNTY, MISSISSIPPI

IN THE MATTER OF:

THE CLAIM OF , A MINOR,

BY , INDIVIDUALLY AND AS

MOTHER AND NEXT FRIEND OF

CAUSE NO.

DECREE AUTHORIZING SETTLEMENT OF DOUBTFUL CLAIM

THIS DAY this cause came on for hearing on the petition of , individually and as mother, general guardian and natural guardian of , a minor, with joinder by , individually and as natural father and natural guardian of , a minor, for authority to settle a disputed claim on behalf of said minor, pursuant to Miss. Code Ann. section 93-13-211 (Supp. 1987), and the Court, having carefully considered the petition, together with the evidence adduced in support thereof, finds as follows:

1.

Petitioner, , is the adult mother, general guardian and natural guardian of , a minor, whose date of birth is . , who joins herein, is the adult natural father, and natural guardian of said minor. Said , , and are each resident citizens of the Judicial District of County, Mississippi.

2.

Said minor has a claim arising from injuries he sustained in the apartment in which he/she lived with his/her mother, at an apartment complex owned and operated by , known as , Mississippi, on , when a air conditioning vent which was negligently and improperly fastened to the wall, fell out of the wall striking him in the face just below his/her left eye, severely cutting his/her left cheek. provided liability insurance on said apartment through a liability policy owned by .

3.

As a result of said injury sustained to , a minor, the following medical expenses have been and will be incurred:

4.

Claims have been made for the abovesaid injuries by , individually and as the parent, general and natural guardian of , a minor. The claim which said minor has is doubtful, not readily collectable and subject to the hazards and perils of litigation. Although and deny all negligence in the premises and for all liability for the injuries incurred, they have agreed to settle all claims arising out of the injuries to , including the claim for bodily injuries of and all claims which said and may have as parents, general guardians and natural guardians of said arising either directly or indirectly out of the bodily injuries sustained by , and all doctor and related health care expenses of arising from said accident and all other claims of every type, kind and character which said and may have arising either directly out of said accident for injuries to said , by paying the total sum of Dollars ($).

5.

Said $ offer of settlement is being paid in exchange for the execution of an Absolute Release with Covenants for all claims and damages of every nature whatsoever which said may have, or which said may have arising either directly or indirectly out of the injuries to said , against and , a copy of said Absolute Release with Covenants being attached to the Petition for Authority to Settle Doubtful Claim and Joinder as Exhibit "A".

6.

That Petitioner has employed , Attorney at Law, in , Mississippi, and said attorney has carefully and thoroughly investigated the facts and circumstances of the aforesaid injury; through discussions with the witnesses, parties and representatives of and has negotiated the aforesaid offer of compromise and settlement; has advised Petitioner and her charge with respect to their claim on account of the injuries to , and the compromise and settlement thereof; and has otherwise rendered valuable legal services to Petitioners. For and in consideration thereof, said attorney has earned and is entitled to receive a reasonable attorney's fee as follows: % of $ the gross proceeds of settlement or $; that Petitioner, has incurred expenses in the amount of $ as set out in the Settlement Sheet attached to the Petition for Authority to Settle Doubtful Claim, with Joinder as Exhibit "B", and should be reimbursed for said expenses, and that the remaining balance of $ should be retained by Petitioner, , for the sole use and benefit of said minor, resulting in a total settlement of $.

7.

That the proposed settlement is a fair and reasonable settlement and it is in the best interest of that said settlement offer be accepted, and Petitioner is of the opinion that said settlement is a fair and reasonable settlement of the claim of said minor, and it would be more prudent to accept said sum of money than subject said minor to the delays and uncertainties of litigation incident to claims of this nature.

IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that, Petitioner, , as mother and next friend, general and natural guardian of , a minor be and hereby is authorized to compromise and settle the claim of the said minor for the sum of dollars ($);

IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Petitioner be and is hereby authorized to execute the Absolute Release with Covenants, attached to the petition as Exhibit "A", fully and finally discharging and releasing , , together with all other parties having any liability in the premises of all rights, claims and causes of action of which said may have, or which said may have arising either directly or indirectly out of the injuries to said , against said and of any kind and character on account of personal injuries and damages sustained by said minor as a result of said accident;

IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Petitioner be and is hereby authorized to pay to attorney's fees in the amount of $ as set forth hereinabove out of said settlement proceeds;

IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Petitioner, be and hereby is authorized to be reimbursed for all expenses incurred on behalf of said minor in the amount of $ as set forth in the Settlement Sheet (Exhibit "B");

IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the remaining settlement proceeds in the amount of $ be retained by Petitioner, , for the sole and exclusive use of ;

IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the requirement of security herein be and is hereby waived;

SO ORDERED, ADJUDGED AND DECREED, this the day of , 20.

Security waiver acknowledged