Petition To Settle Wrongful Death And Survival Actions Page 4
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105-19-16
17.
The pecuniary loss suffered by the beneficiaries listed in Paragraph 16 is as follows:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________
(If additional space is needed, please continue on a separate page).
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 of Costs
b.
To: __________________________
$
Costs
c.
To: __________________________
$
Counsel Fees
d.
Wrongful Death Claim
i.
To: Spouse; and/or
$
ii.
To: Adult Child(ren); and/or
$
iii.
To: Minor Child(ren) and/or
incapacitated persons; and/or
$
(a)
in restricted accounts; or
$
(b)
to the guardian of the minor(s)
$
estate; and/or
iv.
To: Parent(s)
$
e. Survival Claim
To: ____________, Administrator/Executor $
of the Estate of _________________, Deceased
Respectfully submitted,
_____________________________
NAME OF ATTORNEY
ATTORNEY FOR PETITIONER
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Counsel is cautioned to specifically provide the requested distribution. Requests that distribution be "as per attached
Order" are not acceptable.
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