$_______________ 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:
[Insert the Guardian ad Litem’s name] shall immediately apply to the Surrogate of
pursuant to R. 4:81 for the appointment of a guardian of the estate of the
It shall be the responsibility of the attorney for the plaintiff to see that this appointment is
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Monies may be withdrawn from said account only upon further order of the Superior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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