Free Petition to Settle a Minor’s Compromise - Pennsylvania

Civil Division

Forms

See JGCR 97-1 on Page 95

IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY FIRST JUDICIAL DISTRICT PLAINTIFF v. DEFENDANT : : : : : CIVIL TRIAL DIVISION TERM, 20___ NO.

PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION1 To The Honorable, the Judges of the Said Court: The Petition of _____________________________, a minor, by his Guardian (see Pa.R.C.P. 2028), by his attorney, _____________________________, Esquire respectfully requests: 1. Petitioner is (see Pa.R.C.P. 2026): __________________________________________________________ . 2. The minor was born on __________________________________________________________________ , and his/her social security number is ______________________________________________________________ . 3. The minor resides with ___________________________________________________________________ at the following address: ________________________________________________________________________ . 4. A guardian (was) (was not) appointed for the minor as follows: ____________________________________________________________________________________________ . A copy of the Order is attached. 5. The minor's mother is __________________________________________________________ who resides at the following address: ________________________________________________________________________ . 6. The minor's father is ___________________________________________________________ who resides at the following address: ________________________________________________________________________ . 7. The defendant is ______________________________________________________ who resides or whose principal place of business at all relevant times was ____________________________________________________ ____________________________________________________________________________________________ . 8. On ____________________________________________ the minor sustained the following injuries at the following location (set forth in detail): ______________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page). 9. A Complaint was filed against defendant(s) as follows: __________________________________________ ____________________________________________________________________________________________ .

1

In the event the Petition involves an Incapacitated Person, appropriate changes are to be made. See Pa.R.C.P. 2051, et seq.

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10. Attached hereto is a report by Dr. _____________________________________________________ dated ___________________________________________________ which sets forth the present condition of the minor. 11. Attached hereto is a statement, under oath, of the minor's parents and/or guardian and/or guardian ad litem certifying the physical and/or mental condition of the minor, as well as the parents' and/or guardian's and/or guardian ad litem's approval of the proposed settlement and distribution. 12. Attached hereto is the written approval of the proposed settlement and distribution by the minor, who is sixteen (16) years of age or older. 13. The following settlement has been proposed2: ________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page.) 14. Counsel is of the professional opinion that the proposed settlement is reasonable due to the following:____ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page.) 15. 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.) 16. The following costs have been incurred by or on behalf of the minor and must be paid from the proceeds of the settlement: _______________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page.) 17. The Department of Public Welfare, or any other entity, does (not) have a claim or lien against the plaintiff(s) as follows: ___________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ (If additional space is needed, please continue on separate page.) 18. Counsel requests a fee in the sum of $____________ which is ____________% per cent of the net settlement payable to the minor. A copy of the retainer agreement is attached. 19. Counsel (has) (has not) and (will) (will not) receive collateral payments as counsel fees for representation involving the same matter from third parties (i.e. subrogation). 20. The net settlement payable to the minor (after deduction of costs and attorney's fees) is $ _____________ .
2

Phila. Civ.R. #2039.1(D)(3)(e) provides that if there is to be an allocation between parents and children or incapacitated persons or among children or other parties, the amounts allocated to each party and specific reasons for such allocation must be set forth. Additionally, if more than one plaintiff is involved, whether minor, adult or incapacitated, Petitioner must set forth the amount each is to receive and shall provide justification for the requested allocation. 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 assumes responsibility for future payments, the present cost of the annuity, as well as the periodic and lump sum payments.

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Civil Division

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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 for Costs To ____________________________________ To_____________________________________ Counsel Fee To: Adult Plaintiff(s) (if applicable) To ___________________________________ , a minor,4 in restricted accounts not to be withdrawn before majority or upon prior leave of Court. OR e. To_________________________ , the Guardian of the Estate of _________________________ , A Minor, appointed or to be appointed by the Orphans' Court of _____________ County, after posting appropriate security. $ ___________________ $ ___________________

b. c.

$ ___________________ $ ___________________

d.

$ ___________________

e.

$ ___________________

________________________________________ Name of Attorney Attorney for Petitioner

3

Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be "as per the attached Order" are not acceptable. Counsel is cautioned that the restricted account must be set up in the name of the minor only (not in the name of the parent as guardian for the minor). See Pa.R.C.P. 2039(b)(2).

4

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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 Action 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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