Forms
Civil Division
IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY FIRST JUDICIAL DISTRICT CIVIL TRIAL DIVISION : : : TERM, 20___ No:
PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTIONS TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The Petition of ___________________________________________, Administrator/Executor of the Estate of ________________________, Deceased, by his attorney,________________________, Esquire, respectfully requests: 1. Petitioner is ________________________ who was appointed Administrator/Executor of the Estate of ________________________, Deceased, on ________________________, 20____, by the Register of Wills of ________________________County. A copy of the Decree of the Register is attached. 2. The plaintiff decedent died on ________________________ as a result of: [set forth relevant information describing the underlying negligence or cause of action as required by Phila. Civ. R. #2206(D)] _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate sheet.) 3. Notice of the institution of the action as required by Pa.R.C.P. 2205 and Phila. Civ. R. #2205 was given on ________________________ to the following individuals: NAME ___________________________________________ ___________________________________________ ADDRESS ______________________________________________ ______________________________________________
___________________________________________ ______________________________________________ (If additional space is needed, please continue on separate sheet.) 4. Pursuant to Phila. Civ. R. #2206(B) Petitioner has served a copy of this Petition on the intestate heirs1 of plaintiff decedent (as provided in 20 Pa.C.S. §2101 et seq.) who are as follows: NAME _________________________________ _________________________________ RELATIONSHIP _______________________ _______________________ ADDRESS ________________________________ ________________________________ ________________________________
_________________________________ _______________________ (If additional space is needed, please continue on separate sheet.)
1
In the event any court has appointed a guardian for a minor heir or incapacitated person, set forth the name of the guardian, the Court date and manner of appointment.
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5. Pursuant to Phila. Civ. R. #2206(B) Petitioner has served a copy of this Petition on the following parties who may have a possible interest: NAME _________________________________ _________________________________ _________________________________ RELATIONSHIP _______________________ _______________________ _______________________ ADDRESS ______________________________ ______________________________ ______________________________
6. Decedent (did) (did not) have a Will. A copy is attached. 7. The following unpaid claims2 have been raised and/or are outstanding in the decedent's estate: CREDITOR __________________________________________ __________________________________________ __________________________________________ AMOUNT DUE ______________________________________________ ______________________________________________ ______________________________________________
8. A Complaint was filed against defendant(s) as follows: __________________________________________ ____________________________________________________________________________________________ . 9. The following settlement has been proposed+: _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on a separate page.) 10. Counsel is of professional opinion that the proposed settlement is reasonable due to the following (state the reasons why in the professional opinion of counsel the settlement is proper): _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page.) 11. Petitioner is of the opinion that the proposed settlement is reasonable. 12. Counsel has incurred the following expenses for which reimbursement is sought (Please set forth in detail): _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page.) 13. Counsel requests counsel fees in the amount of $____________ which represents _____% of the net proceeds of the settlement.
2
Petitioner must indicate whether the Department of Public Welfare has a claim or a lien against Petitioners, the Estate or any wrongful death beneficiaries. assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments.
+ In the event a portion of the settlement is payable through the purchase of an annuity, set forth the credit rating of the entity which
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14. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorney's fees) as follows: a. b. Wrongful Death Claim Survival Claim $____________________ $____________________
15. The reason for the requested allocation are as follows: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on a separate page.) 16. Pursuant to the Wrongful Death Statute (42 Pa.C.S. §8301), the beneficiaries of the Wrongful Death Claim, and the proportion of their interest, are as follows: NAME __________________________________________ __________________________________________ AMOUNT DUE ______________________________________________ ______________________________________________
17. The pecuniary loss suffered by the beneficiaries listed in Paragraph 16 is as follows: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on a separate page.)
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WHEREFORE, Petitioner requests that he/she be permitted to enter into the settlement recited above, and that the Court enter an Order of Distribution3 as follows: a. To: ____________________________________ Reimbursement of Costs To: ____________________________________ Costs To: _____________________________ , Esquire Counsel Fees Wrongful Death Claim i. ii. To: Spouse; and/or To: Adult Child(ren); and/or $ ___________________ $ ___________________ $ ___________________
b.
$ ___________________
c.
$ ___________________
d.
iii. To: Minor Child(ren) and/or incapacitated persons; and/or a) in restricted accounts; or b) to the guardian of the minor(s) estate; and/or iv. To: Parent(s) e. Survival Claim To: ________________ , Administrator/Executor of the Estate of __________________ , Deceased
$ ___________________ $ ___________________
$ ___________________ $ ___________________
$ ___________________
Respectfully submitted, ________________________________________ NAME OF ATTORNEY ATTORNEY FOR PETITIONER
3
Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be "as per attached Order" are not acceptable.
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VERIFICATION
I, ______________________________, am the Petitioner in this action and hereby verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Actions are true and correct to the best of my knowledge, information and belief. I understand that the statements in said Petition are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities.
DATE: _______________________________________
________________________________________ PETITIONER
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IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY FIRST JUDICIAL DISTRICT CIVIL TRIAL DIVISION PLAINTIFF v. DEFENDANT : : : : : NOTICE PURSUANT TO PHILA. CIV. R. #2206 TERM, 20___
NO:
TO: _______________________________________ (Name of Beneficiary) DATE: ____________________________________
YOU ARE HEREBY NOTIFIED THAT, ___________________________________, Administrator/Executor of the Estate of ____________________________________________________, Deceased has filed (or will file) on ____________________________, A Petition to Approve a Settlement of a Wrongful Death and Survival Action. A copy of that Petition is enclosed. If you object to the proposed settlement and/or proposed distribution, you must submit your written objections or Response to the Petition or on or before* ___________________________________, 20____, to the following address: Civil Administration, Room 296 City Hall, Philadelphia, Pennsylvania 19107. I hereby certify that the within Notice has been mailed to the above named individual(s) on the date set forth above.
________________________________________ NAME OF ATTORNEY ATTORNEY FOR PETITIONER
*Unless waived by all beneficiaries or interested parties, the response period shall be thirty (30) days.
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