Fill and Sign the State of Louisiana Department of Health and Hosptial Vital Form

STATE OF LOUISIANA PARISH OF ______ By virtue of the annexed commission, I, the undersigned Notary Public in and for the Parish of ______ , Louisiana, did proceed to take an inventory and appraisal of the property pointed out to me as belonging to the minor, ____________ , situated in the Parish of ______ , Louisiana, being assisted by ____________ and ____________ , good and competent appraisers, and in the presence of the attesting witness es, undersigned, all of the Parish of ______ , Louisiana, said inventory being as follows, to -wit: Claim for damages against ____________ , ____________ and ____________ , as a result of an accident which occurred on or about ______ ___ , 20 ___ , in the Parish of ______ , Louisiana. VALUE OF CLAIM $ ______ ____________ . VALUE OF CLAIM $ ______ THEREFORE, knowing of no o ther property, and no other property being pointed out to us as belonging to said minor, we have closed this inventory in the amount of ____________ AND ___ /100 ($ ______ ) DOLLARS, with respect to the minor, ____________ , in his claim against ____________ , ____________ and ____________ . THUS DONE AND SIGNED in the Parish of ______ , Louisiana, on this __________ da y of ______ , 20 ___ , in the presence of the undersigned competent witnesse s. WITNESSES: _______________________________ ________________________________ APPRAISER _______________________________ ________________________________ APPRAISER _______________________________ NOTARY PUBLIC