Daup. Cnty. Pa. 2206A
In Re: Estate of ___________, Deceased | : | In the Court of Common Pleas Dauphin County, Pennsylvania |
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ORDER
AND NOW THIS _______ day of ________, 20____, upon consideration of the Petition to Settle Wrongful Death and Survival Actions, it is hereby ordered that the Petitioner is authorized to enter into a settlement in the gross sum of __________. Petitioner is authorized to sign a release and to mark the matter settled, discontinued and ended as to the defendant(s).
The settlement proceeds shall be distributed as follows:
TO: _____________, attorney at law, $_____ for counsel fees;
TO: _____________, attorney at law, $_____ for reimbursement of costs;
The balance of the settlement is apportioned as follows:
Wrongful Death Action $_______________
TO: (spouse)
TO: (child)
TO: (other)
Survival Action $_______________
TO: _______________, personal representative of the Estate of ____________.
BY THE COURT:
__________________________
J.
Daup. Cnty. Pa. 2206A