Free Untitled-14 - Pennsylvania

In the Court of Common Pleas of Philadelphia County First Judicial District of Pennsylvania

Joint General Court Regulation Trial Division and Orphans' Court Division No. 97-1

Wrongful Death and Survival Actions Checklist
Settlement/Trial Division Judge: Caption: Is this case disposed except for this petition? If Yes, how was it disposed? ___S.D.& E. ___Yes ___No ___Non-Jury Trial (Incls. Assessment of Damages) Court Term: Number:

___Jury Trial

___Other (explain)________________________________________________________________________________________________

Consolidated Cases (Indicate Court Term and Number)________________________________________________________ Any Pleadings filed in Orphans' Court: Yes No

Are the following items included in the Petition:
1. Verification from Administrator/Executor 2. If guardian of estate was appointed, is Order attached 3. Notice letter to all parties in interest is attached 4. Counsel's reasons for approval of proposed settlement 5. Reasons for the allocation between wrongful death and survival action 6. Reason and amount of pecuniary loss suffered by each beneficiary of Wrongful Death Claim 7. Petition signed by counsel 8. Department of Welfare or any other entity claim or lien 9. Does the Order of Distribution set forth the following: a. Itemization of costs for reimbursement

Yes

No

b. Counsel fee computed on net settlement c. Wrongful Death Claim i. Amount to spouse and adult children

ii. Amout to minor/incapacitated person (in restricted accounts, typically if under $350,000) iii. Amount to Guardian of minor/incapacitated person (typically if over $350,000) iv. Parent d. Survival Claim: To Administrator/Executor of the Estate of the Deceased e. Affidavit will be filed certifying compliance with the Order

I verify the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers.
11-10 (Rev. 5/98)