Form 22.4 - Report Of Distribution And Entry Of A Minor'S Claim

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PROBATE COURT OF CUYAHOGA COUNTY, OHIO
Anthony J. Russo, Presiding Judge
Laura J. Gallagher, Judge
IN THE MATTER OF __________________________________________________________
CASE NUMBER:______________________________________
REPORT OF DISTRIBUTION OF A MINOR'S CLAIM
Pursuant to Entry filed ___________________________ , _______ , the proceeds have been paid as shown below
and on the accompanying vouchers.
Gross Proceeds
$ _________________
Less:
Medical expenses ________________________________
$ __________________
Reimbursement of suit expenses to __________________
_______________________________________________
$ __________________
Attorney fees to __________________________________
$ __________________
Loss of service to ________________________________
$ __________________
Other: _________________________________________
$ __________________
Total
$ _________________
Net proceeds
9
Deposited pursuant to R.C. 2109.13
Form 22.3 attached
$ __________________
9
Delivered to ______________________________ ,
legal guardian of the estate
$ __________________
9
Delivered to ______________________________ ,
parent__and natural guardian__
$ __________________
9
Delivered to ______________________________ ,
the person by whom the minor is maintained
$__________________
9
Structured - see documents previously filed
$ __________________
Balance
$_________0________
_________________________________________
____________________________________________
Attorney for Applicant
Applicant
________________________
Attorney Registration No.
ENTRY
The above report of distribution is hereby approved and the applicant is discharged from further responsibility.
_________________________________________
____________________________________________
Date
Probate Judge
FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY OF A MINOR’S CLAIM
10/1/98

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