Report Of Distribution Of Wrongful Death And Survival Claims Form
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2PROBATE COURT OF ________________ COUNTY, OHIO
ESTATE OF _______________________________________________________, DECEASED
CASE NO. _______________________
REPORT OF DISTRIBUTION OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
Pursuant to Entry filed _______________________________, _______, the proceeds have been paid as shown
below and on the accompanying vouchers.
Gross Proceeds
$ _______________________________
Funeral and burial expenses
$ _________________________
Fiduciary fees to _____________________
$ _________________________
Reimbursement of case expenses to
___________________________________
$ _________________________
Attorney fees to ______________________
$ _________________________
Survival claim to the estate
$ _________________________
Total Deductions
$ _________________________
Net Proceeds
$ _______________________________
Net proceeds to beneficiaries:
To: ________________________________
$ _________________________
To: ________________________________
$ _________________________
To: ________________________________
$ _________________________
To: ________________________________
$ _________________________
To: ________________________________
$ _________________________
To: ________________________________
$ _________________________
To: ________________________________
$ _________________________
Total payments to beneficiaries
$ _______________________________
Balance
-0-
The fiduciary states that there are no other assets remaining in the estate.
The fiduciary states that there are assets remaining in the estate.
_________________________________________
_________________________________
Attorney for Fiduciary
Fiduciary
Attorney Registration No. ____________________
FORM 14.3 - REPORT OF DISTRIBUTION OF WRONGFUL DEATH AND SURVIVAL CLAIMS
4/1/97
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