THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
FIRST JUDICIAL DISTRICT

PLAINTIFF : CIVIL TRIAL DIVISION
:
v. : TERM, 19
:
DEFENDANT : NO:

PETITION FOR LEAVE TO SETTLE OR
COMPROMISE MINOR'S ACTION(1)

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: __________________

____________________________________________.

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 proposed:(2) _________________________ __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

(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

attorneys fees) is $_________________________________________________________.

WHEREFORE, Petitioner requests that he/she be permitted to enter into the

settlement recited above and that the Court enter an Order of Distribution(3) as follows:

_________________________
Name of Attorney
Attorney for Petitioner

1In the event the Petition involves an Incapacitated Person, appropriate changes are to be made. See Pa. R.C.P. 2051, et seq.

2Phila. 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.

3 Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be "as per the attached Order" are not acceptable.

4 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).


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