Petition For Leave To Settle Or Compromise Minors Action Page 3
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_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.
(If additional space is needed, please continue on separate page.)
16) The Department of Human Services, or any other entity, does (not) have a claim or lien against
the plaintiff(s) as follows ___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.
(If additional space is needed, please continue on separate page.)
17) Counsel requests a fee in the sum of $_______________ which is ________________% per
cent of the net settlement payable to the minor. A copy of the retainer agreement is attached.
18) Counsel (has) (has not) and (will) (will not) receive collateral payments as counsel fees for
representation involving the same matter from third parties (i.e. subrogation).
19) The net settlement payable to the minor (after deduction of costs and attorney’s fees) is
$_________________________.
WHEREFORE, Petitioner requests that he/she be permitted to enter into the settlement
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recited above and that the Court enter an Order of Distribution
as follows:
a)
To _______________________________
$_________________
Reimbursement for Costs
b)
To _______________________________
$_________________
c)
To _______________________________
$_________________
Counsel Fee
d)
To: Adult Plaintiff(s) (if applicable)
$_________________
e)
To ____________________________, A
$_________________
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Minor,
in restricted accounts not to be
withdrawn before majority or upon prior
leave of Court.
OR
f)
To _________________, the Guardian of
$_________________
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Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be “as per the attached Order”
are not
acceptable.
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Counsel is cautioned that the restricted account must be set up in the name of the minor only (not in the name of the parent as
guardian for the minor). See Pa.R.C.P. No. 2039(b)(2).
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