[Reverse of Form 14.0]
CASE NO. _____________________
□
A statement in support of the proffered settlement is attached.
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Supplemental forms required by local rule of court are attached.
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All of the beneficiaries of the wrongful death action are on equal degree of consanguinity, are adults, and have
agreed how the net proceeds allocated to the wrongful death claim are to be distributed.
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The beneficiaries of the wrongful death action are not all on equal degree of consanguinity, or one or more of
the beneficiaries is a minor, or the beneficiaries have not agreed how the net proceeds are to be distributed.
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The surviving spouse, children, and parents of the decedent and the other next of kin who have suffered
damages by reason of the wrongful death are as follows and the distribution should be as follows:
________________________________________________________________________________________
Name
Residence
Relationship
Birthdate
Amount
Address
to Decedent
of Minor
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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The survival claim beneficiaries are as follows:
________________________________________________________________________________________
Name
Residence
Relationship
Birthdate
Amount
Address
to Decedent
of Minor
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
The fiduciary requests that the Court approve the application and authorize the fiduciary to execute a
(complete) (partial) release which upon payment of the settlement shall be a (complete) (partial) discharge of
the claim.
____________________________________
____________________________________
Attorney for Fiduciary
Fiduciary
Attorney Registration No. _______________
ENTRY SETTING HEARING AND ORDERING NOTICE
The Court sets ___________________________________ at _____________ o’clock _____.m. as the date
and time for hearing the above application and orders notice to be given by the fiduciary, as provided in the
Rules of Civil Procedure, to the wrongful death and survival claim beneficiaries who have not waived notice.
__________________________________________
__________________________, Probate Judge
FORM 14.0 – APPLICATION TO APPROVE SETTLEMENT AND DISTRIBUTION OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
Amended: January 1, 2015
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