Form 22.4 - Report Of Distribution Minor'S Claim - Ohio
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1PROBATE COURT OF ___________________ COUNTY, OHIO
IN THE MATTER OF ___________________________________________________
CASE NO. ___________________
REPORT OF DISTRIBUTION 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
Deposited pursuant to R.C. 2109.13
Form 22.3 attached
$ __________________
Delivered to __________________________________________,
legal guardian of the estate
$ __________________
Delivered to __________________________________________,
parent _ and natural guardian_
$ __________________
Delivered to __________________________________________,
the person by whom the minor is maintained
$ __________________
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
Print Form
FORM 22.4 - REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM
4/1/97
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