PROBATE COURT OF __________________ COUNTY, OHIO
IN THE MATTER OF ___________________________________________________ CASE NO. ___________________
WAIVER AND CONSENT TO SETTLE MINOR'S CLAIM
The undersigned, waive all claims for damages on account of loss of services of said minor, waive notice of the hearing, and consent to and approve the Form 22.0, Application To Settle Minor's Claim, a copy of which is attached hereto.
________________________________________ ________________________________________ Typed or Printed Name ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
_______________________________________ _______________________________________ Typed or Printed Name _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________
FORM 22.1 - WAIVER AND CONSENT TO SETTLE MINOR'S CLAIM
4/1/97