Form 22.5 - Application To Settle A Claim Of An Adult Ward - Ohio
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2PROBATE COURT OF________________ COUNTY, OHIO
_____________
, JUDGE
_________________________________________________
IN THE MATTER OF
____________________
CASE NO.
APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD
[R.C. 2111.18, Sup.R. 69]
[Check applicable boxes, complete applicable blanks, strike inapplicable language, and attach supporting
documentation.]
The applicant states that:_____________________________________________________, is an adult
ward residing at __________________________________________________in this county who on or
about ___________________________, suffered personal injury and/or damage to property by wrongful
act, neglect, or default that entitles this person to maintain an action to recover damages.
Attached is a narrative statement in support of the proffered settlement setting forth a description of the
occurrence, the injury or damage, the treatment progress and current prognosis by the treating physicians,
and other proposed or actual settlements resulting from the same occurrence being paid to the persons
other than this ward. Counsel will advise at the hearing as to liability and collectability.
□
There is a (full) (partial) settlement offer of $______________________ without suit being filed.
□
There is a (full) (partial) settlement offer of $_______________________after suit was filed; the
style of the case, court, and case number being _______________________________________.
□
The proffered settlement should be approved.
□
Unreimbursed medical and other expenses of $________________________ have been incurred.
Attached is a list of such expenses and proposed payees.
□
A reasonable attorney fee for the attorney’s services is $_______________________ and
reimbursement to the attorney for suit expenses is $_________________________. A copy of the
attorney’s fee contract that has (has not) received prior approval of this Court, subject to
modification, and an itemization of suit expenses are attached.
□
This is a structured settlement. All necessary documents, including a statement of the present value
of the settlement, are filed herewith.
FORM 22.5 – APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD
Effective Date: January 1, 2015
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