TERM, 19 NO:
FIRST JUDICIAL DISTRICT
CIVIL TRIAL DIVISION
| : | TERM, 19 |
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| : | NO: |
AND NOW, this day of, 19, upon consideration of the
Petition to Compromise Wrongful Death and Survival Action filed on _____________,
19___, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into
a settlement with Defendant(s) ____________________, in the gross sum of
____________________ ($_____________) Dollars. Defendant(s) shall forward all
settlement drafts or checks to Petitioner's counsel for proper distribution.
IT IS FURTHER ORDERED and DECREED that the settlement proceeds are
allocated as follows:
| 1. | Wrongful Death | $__________________ |
| 2. | Survival Claim | $__________________ |
IT IS FURTHER ORDERED and DECREED that the settlement proceeds be
distributed as follows:
| 1. | To: _______________________, Esquire For Costs | $______________ |
| 2. | To: _______________________, Esquire For Counsel Fees | $______________ |
| 3. | The Wrongful Death Claim in the sum of shall be paid as follows: | $______________ |
| a. To: Spouse; and/or | $______________ |
| b. To: Adult Child(ren);* and/or __________________ | $______________ |
| c. To: Minor Child(ren)+ as provided hereunder | $______________ |
| To: __________________________, Guardian $_______________
of the Estate of _____________________, a minor; provided, however, that no payment shall be made to the guardian until the guardian has posted additional security as may be required by the Orphans' Court Division of _____________________ County pursuant to 20 Pa. C.S. §5121, et seq. An appropriate Petition shall be filed with the Orphans' Court within thirty (30) days. |
| Counsel is hereby authorized to execute all
documentation necessary to purchase saving certificate(s), from federally insured banks or savings institutions having an office in Philadelphia County, in the sum of $___________, each not to exceed the insured amount, with the funds payable to the minor upon majority. The certificate shall be titled in the name of the minor and shall be restricted as follows: Not to be redeemed except for renewal in its
Not to be withdrawn before the minor attains
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*In the event the beneficiary is an incapacitated person, appropriate changes are to be made.
+In the event part of the settlement proceeds are payable through the purchase of an
annuity, the terms of the annuity shall be set forth in the Order.
cc: Register of Wills of ________________________ County.
d. To: Parent(s) $______________
4.The Survival Claim in the sum of $______________
shall be paid to ______________, Administrator/Executor, of
the Estate of ____________________, Deceased; provided,
however, that counsel shall not distribute any funds to the
said Administrator/Executor until the additional security as
may be required by the Register of Wills of
____________________ County pursuant to 20 Pa. C.S.
§3323(b)(3) is posted.
Within sixty (60) days from the date of this final Order, counsel shall file with the office of Civil Administration an Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of the Certificate of Deposit and/or bank account containing the required restrictions.
BY THE COURT:
_________________________________
J.
ORPHANS' COURT DIVISION