Free Microsoft Word - Minor Settlement Series 22.DOC - Ohio

PROBATE COURT OF ___________________ COUNTY, OHIO
IN THE MATTER OF ___________________________________________________ CASE NO. ___________________

REPORT OF DISTRIBUTION MINOR'S CLAIM
Pursuant to Entry filed _____________________________, ______, the proceeds have been paid as shown below and on the accompanying vouchers. Gross Proceeds Less: Medical expenses Reimbursement of suit expenses to_____________________ _________________________________________________ Attorney fees to _________________________________ Loss of service to ________________________________ Other: __________________________________________ Total Net Proceeds Deposited pursuant to R.C. 2109.13 Form 22.3 attached Delivered to __________________________________________, legal guardian of the estate Delivered to __________________________________________, parent _ and natural guardian_ Delivered to __________________________________________, the person by whom the minor is maintained Structured - see documents previously filed Balance _________________________________________ Attorney for Applicant Attorney Registration No. __________________ ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. $_____________________

$ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ _____________________

$ __________________

$ __________________

$ __________________

$ __________________ $ __________________ $ -0_______

________________________________________ Applicant

______________________________ Date

_________________________________________ Probate Judge

FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM

4/1/97