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                 MC-351 ATTO RNEY O R P AR TY W IT H O UT A TTO RNEY ( N am e, s ta te b ar n um ber, a nd a ddre ss):F O R C O URT U SE O NLYT E LE PH O NE N O .FA X N O . ( O ptio nal) :E -M AIL A D DR ESS ( O ptio nal) :A TTO RNEY F O R ( N am e):S U PER IO R C O URT O F C ALIF O RNIA , C O UNTY O F STR EE T A D DRESSM AIL IN G A D D RESSC IT Y A N D Z IP C O DEBR AN CH N AM EC ASE N AM E:O RDER A PPR O VIN G C O M PR O M IS E O F C LA IMC ASE N UM BERM IN O RIN CO M PETE N T P ER SO N1 - P etit io ner ( n am e):h as p etit io ned f o r t h e a ppro va l o f t h e p ro pose d c o m pro m is e o f c la im . T his m atte r c a m e o n f o r h earin g o n ( d ate ):a t ( tim e):in D ept.:2. Relationship to claimant Pe tit io ner is c la im ant's :a.P are nt.b .G uard ia n a d lit e m .c.Guard ia n.d.C onse rv a to r.e .O th er ( s p ecif y ):3. Claimant (name): a.is a m in or.b .is a n in co m pete nt p ers o n.4. DefendantThe c la im t o b e c o m pro m is e d is a sse rte d a gain st ( n am e o f s e ttlin g d efe ndant o r d efe ndants ( th e 'p aye r') ):T H E C O URT O RDER S 5. T he p etit io n is g ra nte d a nd t h e c o m pro m is e is a ppro ve d.6. T he p aye r s h all d is b urs e t h e p ro ce eds o f t h e s e ttle m ent a ppro ve d b y t h is o rd er in t h e f o llo w in g m anner:a. Payment of fees and expensesFees a nd e xp ense s s h all b e p aid b y o ne o r m ore c h ecks o r d ra fts , d ra w n p aya ble t o t h e o rd er o f t h e p etit io ner a nd t h e petit io ner's a tto rn ey, if a ny, o r d ir e ctly t o t h ose e ntit le d t o r e ce iv e p aym ent, f o r t h e f o llo w in g it e m s o f e xp ense o r d am age, w hic h are h e re by a uth oriz e d t o b e p aid o u t o f t h e p ro ce eds o f s e ttle m ent:( 1 )A tto rn ey's f e es in t h e a m ount o f: $P aya ble t o ( s p ecif y ):(2 )R eim burs e m ent f o r m edic a l a nd o th er e xp ense s p aid b y t h e p etit io ne r in t h e a m ount o f: $ pa ya ble t o t h e p etit io ner.P age 1 o f 3F orm A dopte d fo r M andato ry U se Ju dic ia l C ouncil o f C alif o rn ia MC -3 51 [R ev. J a nuary 1 , 2 007] C od e o f C iv il P ro ce dure , § 3 72 e t s e q., O RDER A PPR O VIN G C O M PR O M IS E O F C LA IM P ro bate C ode, § 3 500 e t s e q.,C al. R ule s o f C ourt, r u le s 3 .1 384, 7 .9 53electronic form 2001-7 WWW.LawCA.com Law Publishers           CASE NAME:CASE N UM BER6 . a . ( 3 )M edic a l, h osp it a l, a m bula nce , n urs in g, a nd o th er lik e e xp ense s in t h e t o ta l a m ount o f: $ pa ya ble a s f o llo w s:(i) Payee (name):(iii) P aye e ( n am e):(a ) A ddre ss:(a ) A ddre ss:(b ) A m ount:( b ) A m ount:( ii) P aye e ( n am e):(iv ) P aye e ( n am e):(a ) A ddre ss:(a ) A ddre ss:(b ) A m ount:( b ) A m ount:C ontin ued ( if th ere a re a ddit io nal p a ye es, a lis t o f s u ch p aye es m ust b e a tta ch ed t o t h is f o rm a s A tta ch m ent 6 a(3 ).)( 4 )O th er a u th oriz e d p aym ents ( s p ecif y ):(5 )T ota l a ll o w an ce f o r f e es a n d e xp en ses: $b. BalanceThe b ala nce o f t h e s e ttle m ent p ro ce eds s h all b e d is b urs e d a s f o llo w s:(1 )d ra w n p aya ble t oB y o ne o r m ore c h ecks o r d ra fts in t h e t o ta l a m ount o f ( s p ecif y ): $ th e o rd er o f t h e p e tit io ner a s t r u ste e f o r t h e c la im ant. E ach s u ch c h eck o r d ra ft s h all b ear a n e ndors e m ent o n t h e face o r r e ve rs e t h a t it is f o r d eposit in a n in te re st- b earin g, f e dera lly in su re d a cco unt in t h e n am e o f t h e p etit io ner a s tru ste e f o r t h e c la im ant, a nd n o w it h dra w als s h all b e m ade f r o m t h e a cco unt w it h out a w rit te n c o urt o rd er ( a ''b lo cke d a cco unt'') .(2 )B y t h e f o llo w in g m eth od ( s p ecif y ):If t h e m eth od in vo lv e s t h e p aym en t o f m oney t o a s p ecia l n eeds t r u st, a ll s ta tu to ry lie ns in f a vo r o f t h e S ta te D epartm ent o f Menta l H ealt h , t h e S ta te D epartm en t o f D eve lo pm enta l S erv ic e s, a nd a ny c it y a nd c o unty in C alif o rn ia m ust f ir s t b e s a tis fie d by t h e f o llo w in g m eth od ( s p ecif y ):7 .B lo cked a cco untsIf t h e c o u rt o rd ers d is tr ib utio n o f t h e b ala nce in to a b lo cke d a cco unt o r a cco unts u nder it e m 6 b(l) , it f u rth er o rd ers :a . W it h in 4 8 h ours o f r e ce ip t o f a c h eck o r d ra ft d escrib ed in it e m 6 b(l) , t h e p etit io ner a nd t h e p etit io ner's a tto rn ey, if a ny, m ustd eposit t h e c h eck o r d ra ft in t h e p e tit io ner's n am e a s t r u ste e f o r t h e c la im ant in a b lo cke d a cco unt a t ( s p ecif y n am e, b ra nch , and a ddre ss o f e ach d eposit o ty ):b . T he p etit io ner a n d t h e p etit io ner's a tto rn ey, if a ny, m ust d eliv e r t o e ach d eposit o ry a t t h e t im e o f d eposit t h re e c o pie s o f t h eO rd er t o D eposit M oney I n to B lo cke d A cco unt ( ''O rd er') , w hic h is s ig ne d c o nte m pora neously w it h t h is o rd er, a nd t h re e c o pie s of t h e R ece ip t a n d A ckn ow le dgm ent o f O rd er t o D eposit M oney I n to B lo cke d A cco unt ( " R ece ip t') . T he p etit io ner o r t h e petit io ner's a tto rn ey m ust f ile a c o py o f t h e R ece ip t w it h t h is c o urt w it h in 1 5 d ays o f t h e d eposit . T he s o le r e sp onsib ilit ie s o f the p etit io ner a re t o p la ce t h e b ala nce in a b lo cke d a cco unt o r a cco unts a nd t o t im ely f ile a c o py o f t h e R ece ip t.P age 2 o f 3M C-3 51 [R ev. J a nuary 1 , 2 007]O RDER A PPR O VIN G C O M PR O M IS E O F C LA IM MC-351             CASE N AM E:CASE N UM BER7 .c. T he b ala nce o f t h e s e ttle m ent p ro ce eds d eposit e d in a b lo cke d a cc o unt u nder it e m 6 b(l) m ay b e w it h dra w n o nly a s f o llo w s (ch eck o nly ( 1 ) o r ( 2 )):(1 )N o w it h dra w als o f p rin cip al o r in te re st m ay b e m ade f r o m t h e b lo cke d a cco unt o r a cco unts w it h out a w rit te n ord er u nd er t h is c a se n am e a nd n u m ber, s ig ned b y a ju dge, a nd b ea rin g t h e s e al o f t h is c o urt. T he m oney o n deposit is n ot s u bje ct t o e sch eat.( 2 )T he b lo cke d a cco unt o r a cco unts b elo ng t o a m in or. T he m in or w as b orn o n ( d ate ): No w it h dra w als o f p rin cip al o r in te re st m ay b e m ade f r o m t h e b lo cke d a cco unt o r a cco unts w it h out a w rit te n ord er u nd er t h is c a se n am e a nd n u m ber, s ig ned b y a ju dge, a nd b ea rin g t h e s e al o f t h is c o urt, u ntil t h e m in or atta in s t h e a ge o f 1 8 y e ars . W hen t h e m in or a tta in s t h e a ge o f 1 8 y e ars , t h e d eposit o ry , w it h out f u rth er o rd er o f this c o urt, is a uth oriz e d a nd d ir e cte d t o p ay b y c h eck o r d ra ft d ir e ctly t o t h e f o rm er m in or, u pon p ro per d em and, all m oneys in clu din g in te re st d eposit e d u nder t h is o rd er. T he m oney o n d eposit is n ot s u bje ct t o e sch eat.8 .A uth oriz a tio n t o e xecu te s ettle m en t d ocu m en ts Th e p etit io ner is a u th oriz e d t o e xe cu te s e ttle m ent d ocu m ents a s f o llo w s ( c h eck o nly o ne):a .U pon r e ce ip t o f t h e f u ll a m ount o f t h e s e ttle m ent s u m a ppro ve d b y t h is o rd er a nd t h e d eposit o f f u nds, t h e petit io ner is a uth o riz e d a nd d ir e cte d t o e xe cu te a nd d eliv e r t o t h e p aye r a f u ll, c o m ple te , a nd f in al r e le ase a nd dis ch arg e o f a ny a nd a ll c la im s a nd d em ands o f t h e c la im ant b y r e aso n o f t h e a ccid ent o r in cid ent d escrib ed in th e p etit io n a nd t h e r e su lt a nt in ju rie s t o t h e m in or, a nd a p ro perly e xe cu te d d is m is sa l w it h p re ju dic e .b.T he p etit io ner is a u th oriz e d a nd d ir e cte d t o e xe cu te a ny a nd a ll d ocu m ents r e aso nably n ece ssa ry t o c a rry o ut t h e term s o f t h e s e ttle m ent.c.T he p etit io ner is a u th oriz e d a nd d ir e cte d ( s p ecif y ):9 .B ond isw aiv e dfix e d in t h e a m ount o f: $1 0. A c o py o f t h is o rd er s h all b e s e rv e d o n t h e p aye r f o rth w it h .11. Other (specify):Date : JU DG E O F T H E S U PER IO R C O URT SIG NATU RE F O LLO W S L A ST A TTA C HM EN T Page 3 o f 3M C-3 51 [R ev. J a nuary 1 , 2 007]O RDER A PPR O VIN G C O M PR O M IS E O F C LA IM MC-351