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Civil Action Form - Judgment Approving Minor'S Settlement And Directing The Deposit/investment Of Funds Page 2

$_______________ to be paid to the plaintiff’s attorney(s) which reimburses

$_____________ for actual disbursements, costs and expenses and satisfies the attorneys’

contingent fees of $____________; and

$________________ for medical bills from the minor’s recovery to be paid as follows:

Payee

Amount

_______________________________

$ ____________________

_______________________________

$ ____________________

_______________________________

$ ____________________

[Insert the Guardian ad Litem’s name] shall immediately apply to the Surrogate of

_____________ County

pursuant to R. 4:81 for the appointment of a guardian of the estate of the

[EN1]

minor.

It shall be the responsibility of the attorney for the plaintiff to see that this appointment is

[EN2]

completed.

ALTERNATIVE 1 -- DEPOSIT NET FUNDS WITH SURROGATE

-STRIKE OUT IF NOT APPLICABLE

Pursuant to R. 4:48A the net recovery of $_______________, payable for the benefit of

the minor plaintiff, shall be paid by or on behalf of the defendant(s) by check payable to the “Surrogate of

___________ County Intermingled Trust Fund F/B/O of [insert minor’s name], a minor,” within ____

days of this Judgment. It is and shall be the responsibility of the attorney for the plaintiff to see that this

deposit is completed.

Upon payment of the minor’s net recovery into the Surrogates’ Intermingled Trust Fund,

the posting of a bond by the person applying to be guardian of the minor’s estate is dispensed with

pursuant to N.J.S.A. 3B:15-16.

Monies may be withdrawn from said account only upon further order of the Superior

Court of New Jersey, Chancery Division, Probate Part, pursuant to N.J.S.A. 3B:15-17, or upon the minor

attaining majority pursuant to N.J.S.A. 3B:15-17.l.

The Guardian ad Litem shall provide the Surrogate with the minor’s Social Security

Number and a copy of the minor’s birth certificate. Personal identifying information shall be redacted

Revised 11/01/2013, Promulgated by Directive #9-08 (05/19/2008), CN 10520-English

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Civil Action Form - Judgment Approving Minor'S Settlement And Directing The Deposit/investment Of Funds Page 2