IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
FIRST JUDICIAL DISTRICT
CIVIL TRIAL DIVISION

:TERM, 19
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O R D E R

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
$______________

OPTION 1
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.
OPTION 2
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
entirety, not to be withdrawn, assigned,
negotiated, or, otherwise alienated before the
minor attains majority, except upon prior Order
of Court.Counsel shall open a savings
account in the sum of $__________________
in the name of the minor. The savings account
shall be restricted as follows:

Not to be withdrawn before the minor attains
majority, except for the payment of city, state,
and federal income taxes on the interest earned
by the savings certificate and savings account,
or upon prior Order of Court.

*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.

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

cc: Register of Wills of ________________________ County.


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