PROBATE COURT OF ________________ COUNTY, OHIO
, JUDGE
ESTATE OF ________________________________________________, DECEASED
CASE NO. ___________________________
APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
[R.C. 2117.05, 2125.02, Civ. R. 19.1 and Sup. R. 70]
The fiduciary states:
[Check whichever of the following are applicable, strike inapplicable words, and incorporate all attachments into a
single statement.]
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There is an offer of (full) (partial) settlement without suit being filed.
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There is an offer of (full) (partial) settlement after suit was filed. The style of the case, the court, and case
number being ___________________________________________________________.
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A judgment has been recovered for damages for the decedent’s wrongful death (and personal injury and
property damage arising out of the same act and which survive the decedent).
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The amount of the settlement or judgment is $___________________________________.
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There is a partial settlement and therefore the estate must remain open pending final disposition of the
claims.
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The offer includes, or the judgment sets forth separately, reasonable funeral and burial expenses in the
amount of $_________________________.
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Reasonable compensation for the fiduciary for services rendered is $_____________________________ and
an itemization of such services is attached.
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Outstanding hospital and medical bills in the amount of $_____________________________ and an
itemization of such bills is attached.
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Outstanding claims to a right of subrogation for the payment of hospital and medical bills in the amount of
$_____________________________ and an itemization of such is attached.
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A reasonable attorney fee for the attorney’s services is $__________________________________ and
reimbursement to the attorney for case expenses is $_____________________________. A copy of the
attorney’s fee contract that (has) (has not) received prior approval of the Court, subject to modification, and
itemization of the case expenses are attached.
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Other: _______________________________________________________________________________
____________________________________________________________________________________.
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The net proceeds of $____________________ should be allocated $_________________ to the wrongful
death action and $____________________ to the survival action. A statement in support thereof is attached.
FORM 14.0 – APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
Amended: January 1, 2015
Discard all previous versions of this form
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