[SEE CAPTION AT 1.3.4 ]
ORDER APPROVING SETTLEMENT
AND ORDER FOR DISTRIBUTION
Now, this day of , 20 , upon consideration of the Petition For Leave to Compromise an Incapacitated Person's Action, filed May 15, 1999, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant Thomas White in the gross sum of One Million Dollars ($1,000,000).
It is further ORDERED and DECREED that the settlement proceeds be distributed as follows:
To: | John K. Trustworthy, Esquire Reimbursement of Costs | $ 15,234.00 |
To: | John K. Trustworthy, Esquire Counsel Fee | 328,255.33 |
To: | Commonwealth of Pa, Dept. of Public Welfare, Payment of Lien | 21,000.00 |
To: | XYZ Life Insurance Co. for the purchase of a structured settlement annuity to make payments of $42,175 per month guaranteed for 20 years and life thereafter, increasing at 3% annually, to commence 8/1/99, in accordance with the Release attached as Exhibit "F." | 300,000.00 |
To: | Henry Doe, Guardian of the Estate of John Dunn, an Incapacitated Person, appointed by the Orphans' Court Division of Philadelphia County, by Decree dated 5/30/98 (O.C. No. 98-643) for distribution to a special needs trust to be approved by the Orphans' Court Division upon petition to be filed within thirty (30) days of this Order; provided, however, that no payment shall be made to the said guardian until the guardian has posted additional security as may be required by the Orphans' Court Division pursuant to 20 Pa. C.S. § 5516, an appropriate Petition shall be filed with the Orphans' Court within thirty (30) days. * [Note: If the funds payable to the incapacitated person are to be placed in one ore more restricted accounts instead of to a guardian or trustee, the Order should be modified to show how the funds will be held and to describe the restrictions.] | 335,510.67 |
Pursuant to Phila. Civ. R. * 2039.1(I), counsel shall file with the office of Civil Administration within sixty (60) days from the date of this final Order proof of the establishment of the accounts for any incapacitated person set forth herein, by Affidavit from counsel certifying compliance with this Order. [Note: If Order requires distribution to one or more restricted accounts, counsel must attach to the Affidavit proof of the deposit and the restriction in the form of a photocopy, CD or a bankbook.]
J.
ORPHANS' COURT DIVISION
[SEE CAPTION AT 1.3.2 ]
PETITION FOR LEAVE TO SETTLE
INCAPACITATED PERSON'S ACTION
The Petition of John Dunn, an Incapacitated Person, by his Guardian, Henry Doe, by his attorney, John K. Trustworthy, Esquire respectfully requests that this Court approve the settlement of the within matter and the distribution of proceeds and in support thereof avers the following:
Wherefore, Petitioner requests that he be permitted to enter into the settlement recited above and that the Court enter an Order of Distribution as follows: **
a. | To: John K. Trustworthy, Esq. Reimbursement for Costs | $ 15,234.00 |
b. | To: John K. Trustworthy, Esq. Counsel Fee | 328,255.33 |
c. | To: Commonwealth of Pa, Dept. of Public Welfare, Payment of Lien | 21,000.00 |
d. | To: XYZ Life Insurance Co. for the purchase of a structured settlement annuity to make payments of $2,175 per month guaranteed for 20 years and life thereafter, increasing at 3% annually, to commence 8/1/99, in accordance with the Release attached as Exhibit "F." | 300,000.00 |
e. | To Henry Doe, Guardian of the Estate of John Dunn, an Incapacitated Person, appointed by the Orphans' Court Division of Philadelphia County, by Decree dated 5/30/98 (O.C. No. 98-643) for distribution to a special needs trust to be approved by the Orphans' Court Division upon petition to be filed within 30 days of the Order. | 335,510.67 |
John K. Trustworthy
Attorney for Petitioner
* Joint Court Regulation 97-1, paragraph I.(b)(4)(d) provides as follows: "If there is to be an allocation between parents and children or incapacitated persons or among children or other parties, the amounts allocated to each party and specific reasons for such allocation must be set forth." Additionally, if more than one plaintiff is involved, whether minors, incapacitated persons or adults, Petitioner must indicate the amount each plaintiff is to receive for his or her injuries and justification for the requested allocation.
** Counsel is cautioned to provide specifically the requested distribution. Requests that distribution be "as per the attached Order" are not acceptable.
Note: In appropriate cases, funds for the incapacitated person may be distributed to a restricted account, not to be withdrawn before majority or upon prior leave of the court. The restricted account must be set up in the name of the incapacitated person only. See Pa. R.C.P. 2064(b)(2).
[SEE AFFIDAVIT AT 1.4.1 OR VERIFICATION AT 1.4.3 ]