IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
FIRST JUDICIAL DISTRICT
CIVIL TRIAL DIVISION
: TERM, 19
:
:
: NO:

PETITION TO SETTLE WRONGFUL
DEATH AND SURVIVAL ACTIONS

TO THE HONORABLE, THE JUDGES OF THE SAID COURT:

The Petition of ________________________, Administrator/Executor of the Estate of __________________, Deceased, by his attorney, ______________________, Esquire, respectfully requests:

1. Petitioner is ____________________ who was appointed Administrator/Executor of the Estate of _____________________, Deceased, on __________________, 19___, by the Register of Wills of _________________ County. A copy of the Decree of the Register is attached.

2. The plaintiff decedent died on ____________________ as a result of:
[set forth relevant information describing the underlying negligence or cause of action as required by Phila. Civ. R. 2206(D)]

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

(If additional space is needed, please continue on separate sheet).

3. Notice of the institution of the action as required by Pa. R.C.P. 2205 and Philadelphia Civ. R. 2205 was given on _______________________ to the following individuals:

NAMEADDRESS:
___________________________________________________________
___________________________________________________________
___________________________________________________________

4. Pursuant to Phila. Civ. R. 2206(B) Petitioner has served a copy of this Petition on the intestate heirs* of plaintiff decedent (as provided in 20 Pa. C.S. §2101 et seq.) who are as follows:

NAMERELATIONSHIPADDRESS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. Pursuant to Phila. Civ. R. 2206(B) Petitioner has served a copy of this Petition on the following parties who may have a possible interest:

NAMERELATIONSHIPADDRESS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. Decedent (did) (did not) have a Will. A copy is attached. ______________________

*In the event any court has appointed a guardian for a minor heir or incapacitated person, set forth the name of the guardian, the Court date and manner of appointment.

7. The following unpaid claims* have been raised and/or are outstanding in the decedent's estate:

CREDITORAMOUNT DUE
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________

8. A Complaint was filed against defendant(s) as follows:

________________________________________________________________________

________________________________________________________________________.

9. The following settlement has been proposed+:

________________________________________________________________________

________________________________________________________________________
(If additional space is needed, please continue on a separate page).

10. Counsel is of the professional opinion that the proposed settlement is reasonable due to the following (state the reasons why in the professional opinion of counsel the settlement is proper):

________________________________________________________________________

________________________________________________________________________
(If additional space is needed, please continue on separate page).

11. Petitioner is of the opinion that the proposed settlement is reasonable.

12. Counsel has incurred the following expenses for which reimbursement is __________________

*Petitioner must indicate whether the Department of Public Welfare has a claim or a lien against Petitioners, the Estate or any wrongful death beneficiaries.

+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.

sought (Please set forth in detail):

________________________________________________________________________

________________________________________________________________________
(If additional space is needed, please continue on separate page).

13. Counsel requests counsel fees in the amount of $___________ which represents _____% of the net proceeds of the settlement.

14. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorneys fees) as follows:

15. The reason for the requested allocation are as follows:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
(If additional space is needed, please continue on a separate page).

16. Pursuant to the Wrongful Death Statute (42 Pa. C.S. §8301), the beneficiaries of the Wrongful Death Claim, and the proportion of their interest, are as follows:

17. The pecuniary loss suffered by the beneficiaries listed in Paragraph 15 is as follows:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
(If additional space is needed, please continue on a separate page).

WHEREFORE, Petitioner requests that he/she be permitted to enter into the settlement recited above, and that the Court enter an Order of Distribution* as follows:
a.To: _______________________
Reimbursement of Costs
$
b.To: _______________________
Costs
$
c.To: _______________________
For Counsel Fees
$
d.Wrongful Death Claim
i. To: Spouse; and/or$
ii. To: Adult Child(ren); and/or$
iii. To: Minor Child(ren) and/or
incapacitated persons; and/or
$
(a) in restricted accounts; or$
(b) to the guardian of the minor(s)
estate; and/or
$
iv. To: Parent(s)$

___________________
*Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be "as per attached Order" are not acceptable.
e.Survival Claim
To: ____________, Administrator/Executor
of the Estate of _________________, Deceased
$

Respectfully submitted,
_________________________________
NAME OF ATTORNEY
ATTORNEY FOR PETITIONER


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