Form WD-7 - Decree
Form WD-7
(Decree)
At a Surrogate's Court of the State of New York held in and for the County of ________, at ________ New York on ________, 19________.
P R E S E N T:
HON.
______
Surrogate
________x
In the Matter of the Application of
________ as Administrat________ of the Goods,
Chattels and Credits which were of
________ DECREE
Deceased, File No. ________
For leave to compromise and settle a certain cause of action for wrongful death of the decedent to render and have judicially settled an account of the proceedings as such Administrat________.
________x
Upon the Petition of ________ as Administrat________ of the Estate of ________, deceased, duly verified the ________ day of ________, 19 ________, and the accounting sworn to the ________ day of ________, 19________, in which application was made for an Order permitting the said, as Administrat________, to compromise and settle for the sum of $ ________ the cause of action against ________ for the wrongful death of the decedent,
And to discontinue the action for conscious pain and suffering and to discharge and release said defendant and insurance company from all suits and claims upon the payment of the said $ ________ in settlement of the cause of action herein,
And that the entire recovery of said action should be allocated to the cause of action for decedent's wrongful death, to modify the Letters of Administration to permit said compromise, dispense with the filing of a bond, judicially settle the account, pay to ________, Esqs., their fee for services rendered, reject the claim of the Department of Social Services, and reject the claims of ________ and ________
And more than seven months having elapsed since the granting of Letters of Administration to ________and the Surrogate having issued a Citation to all persons interested in the estate of said deceased to attend such judicial settlement on the ________ day of ________, 19________, at 9:30 a.m., at the Surrogate's Court, ________ County,
And the said Citation having been duly returned with proof of due service thereof, or the due appearance and waiver of notice, by the following named person or corporations, to wit:
[List names of distributees, and, if applicable, New York City Department of Social Services New York State Tax Commission, Defendant, and Defendant's Insurance Company]
And the said ________, petitioner herein, having appeared by ________, his/her attorney,
And the said ________ having appeared by ________, his/her attorneys, and having filed objections to said account,
And the said ________ having appeared by ________, his/her attorney, and having filed objections to said account,
And said New York City Department of Social Services having appeared by ________, its attorney, and having filed objections to said account,
And said New York State Tax Commission having appeared by ________, its attorney, and having filed objections to said account,
And the Court having appointed ________, as Guardian ad Litem for ________,
And the Court having appointed ________, as Guardian ad Litem for ________,
And ________ having filed objections on behalf of his/her ward ________,
And ________ having filed a report as such guardian,
And a hearing having been held, and the Court having rendered a decision dated ________, granting the petition to compromise the cause of action for wrongful death and to judicially settle the account,
And the Court having examined the said account and having found the state and condition of said account to be as set forth in the following statement recorded with the Court:
SUMMARY STATEMENT OF THE SETTLEMENT PROCEEDS
The Administrat________ is charged with the proceeds of the action of wrongful death to be distributed. $ ________
TOTAL CHARGES $ ________
The Administrat________ is credited with the following amounts $ ________
TOTAL CREDITS $ ________
BALANCE OF THE SETTLEMENT PROCEEDS
TO BE DISTRIBUTED $ ________
And it appearing the said Administrat ________ has fully accounted for all monies and properties of the estate in said summary statement, and the Administrat ________ having waived any claim to statutory commissions, it is hereby
ORDERED, ADJUDGED AND DECREED that the petitioner's application for leave to compromise and settle the cause of action for wrongful death and to allocate the entire amount of the proceeds to the cause of action for wrongful death and to grant leave to discontinue the cause of action for conscious pain and suffering is granted; and it is further
ORDERED, ADJUDGED AND DECREED that the petitioner as Administrat ________ of the decedent's estate is authorized to settle and discontinue the claims and causes of action for conscious pain and suffering and wrongful death against the defendant, ________, and petitioner is authorized to deliver general releases and discontinuances and any other papers or documents that may be required to effectuate a settlement and discontinuances or withdrawals of the said claims and causes of actions for conscious pain and suffering and wrongful death; and it is further
ORDERED, ADJUDGED AND DECREED that the entire settlement sum of $ ________ is allocated to the cause of action for wrongful death, and the personal injury action is discontinued with prejudice and without interest, costs or disbursements; and it is further
ORDERED, ADJUDGED AND DECREED that the entire settlement sum of $ ________ be paid by the defendant, or defendant's insurance company ________ as follows:
To ________, as fee for services $ ________ as Guardian ad Litem
To ________, as fee for $ ________services as Guardian ad Litem
To ________, as fee for $ ________ services as attorney for the Administrat________ herein
To ________, in reimbursement of $ ________ disbursements as attorney for the Administrat ________ herein
To ________, as and for his/her share as surviving spouse and beneficiary of said decedent pursuant to section 5-4.4 of the Estates, Powers and Trusts Law, equal to ________ % $ ________
To ________, child and next of kin by payment to ________, Guardian of the property of ________, jointly with the Guardianship Clerk of Surrogate's Court, as and for his/her share as next of kin of said decedent pursuant to section 5-4.4 of the Estates, Powers and Trusts Law, equal to ________ % $ ________
and it is further
ORDERED, ADJUDGED AND DECREED that the claims of the Department of Social Services, the New York State Tax Commission, and ________ hereby are disallowed and objections filed by these parties are dismissed; and it is further
ORDERED, ADJUDGED AND DECREED that upon the defendant, ________, or defendant's insurance company, making payments as aforesaid, ________, as Administrat________ of the estate of ________, deceased, be and hereby is discharged from any and all further liability as to all matters and things embraced in the aforesaid account and determined by this decree; and it is further
ORDERED, ADJUDGED AND DECREED that the giving of a bond or other security in connection therewith be dispensed with, and that the restrictions on the Letters of Administration be modified to allow the above settlement; and it is further
ORDERED, ADJUDGED AND DECREED that the account of, as Administrat________, is hereby judicially settled.
______________
Surrogate