Free Microsoft Word - Wrongful Death Series 14.DOC - Ohio

PROBATE COURT OF ________________ COUNTY, OHIO
ESTATE OF _______________________________________________________, DECEASED CASE NO. _______________________

REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS
Pursuant to Entry filed _______________________________, _______, the proceeds have been paid as shown below and on the accompanying vouchers. Gross Proceeds Funeral and burial expenses Fiduciary fees to _____________________ Reimbursement of case expenses to ___________________________________ Attorney fees to ______________________ Survival claim to the estate Total Deductions Net Proceeds Net proceeds to beneficiaries: To: ________________________________ To: ________________________________ To: ________________________________ To: ________________________________ To: ________________________________ To: ________________________________ To: ________________________________ Total payments to beneficiaries Balance The fiduciary states that there are no other assets remaining in the estate. The fiduciary states that there are assets remaining in the estate. $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _______________________________ -0$ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _______________________________ $ _______________________________ $ _________________________ $ _________________________

_________________________________________ Attorney for Fiduciary Attorney Registration No. ____________________

_________________________________ Fiduciary

FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS

4/1/97

(Reverse of Form 14.3)

ENTRY

The above report of the distribution of the proceeds is hereby approved. There being no further assets to administer, the fiduciary and surety, if any, are discharged.

_____________________________ Date

_____________________________________ PROBATE JUDGE