Petition To Compromise Doubtful Claim Of Minor/adult Ward

There are all sorts of forms executors, beneficiaries, and probate court clerks have to fill out and correspond with during probate and estate settlement, including affidavits, letters, petitions, summons, orders, and notices.

Petition To Compromise Doubtful Claim Of Minor/adult Ward is a commonly used form within Georgia. Here’s an overview of what the form is and means, including a breakdown of the situations when (or why) you may need to use it:

Atticus Fast Facts About Petition To Compromise Doubtful Claim Of Minor/adult Ward

Sometimes it’s tough to find a quick summary— here’s the important details you should know about Petition To Compromise Doubtful Claim Of Minor/adult Ward:

• This form pertains to the State of Georgia

Government forms are not typically updated often, though when they are, it often happens rather quietly. While Atticus works hard to keep this information about Georgia’s Form GPCSF 19 - Petition To Compromise Doubtful Claim Of Minor/adult Ward up to date, certain details can change from time-to-time with little or no communication.

Step 1 - Download the correct Georgia form based on the name and ID if applicable

Double check that you have both the correct form name and the correct form ID. Some Georgia probate forms can look remarkably similar, so it’s best to double, even triple-check that you’re using the right one! Keep in mind that not all States have a standardized Form ID system for their probate forms.

Step 2 - Complete the Document

Fill out all relevant fields in Form GPCSF 19, take a break, and then review. Probate and estate settlement processes in GA are long enough to begin with, and making a silly error can push your timeline even farther back. No thank you!

Note: If you don’t currently know all of the answers and are accessing Form GPCSF 19 online, be sure to avoid closing the browser tab and potentially losing all your progress (or use a platform like Atticus to help avoid making mistakes).

Step 3 - Have Form GPCSF 19 witnessed or notarized (if required)

Some States and situations require particular forms to be notarized. If you have been instructed to get the document notarized or see it in writing on the document, then make sure to hire a local notary. There are max notary fees in the United States that are defined and set by local law. Take a look at our full guide to notary fees to make sure you aren’t overpaying or getting ripped off.

Step 4 - Submit Petition To Compromise Doubtful Claim Of Minor/adult Ward to the relevant office

This is most often the local probate court where the decedent (person who passed away) is domiciled (permanently resides) or the institution involved with this particular form (e.g. a bank). Some offices allow you to submit forms online, other’s don’t, and we while we generally recommend going in-person to expedite the process, sometimes that simply isn’t an option.

It’s also a generally good idea to establish a positive working relationship with any probate clerk (unfortunately there’s enough people & process out there making things more difficult and unnecessarily confusing for them), so a best practice is to simply ask the probate clerk proactively exactly how and where they’d prefer you to submit all forms.

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Different probate forms or processes can require different deadlines or response times for completing the appropriate form.

While some steps in the process are bound to specific deadlines (like petitioning for probate, having to submit an inventory of assets, or filing applicable notices to creditors and beneficiaries), many probate forms or processes are not tied to a specific deadline since the scope of work can vary based on situational factors or requirements involved.

Either way, there are a bunch of practical reasons why personal representatives should work to complete each step as thoroughly and quickly as possible when completing probate in Georgia.

5 reasons you should submit GPCSF 19 as quickly as possible:

1. The sooner you begin, the faster Georgia can allow heirs and beneficiaries to get their share of assets subject to probate. Acting promptly can also decrease the costs & overall mental fatigue through an otherwise burdensome process.
   
   Helpful Context: What’s the Difference Between Probate and Non-Probate Assets?

2. In general, creditors of an estate usually have around 3-6 months from the time you file notice to creditors to file any claims for debt against the deceased’s assets. If they don’t, then that debt is forfeited (and more importantly, the executor won’t be held personally responsible). So doing this sooner means you have a better idea of who is owed what and ensures you won’t get a surprise collector months later.

3. Not filing a will within 30 days (on average) could mean that the probate process proceeds according to intestate laws (laws that govern what happens to someone's stuff without a will) or is subject to unnecessary supervision by the probate court. And if you aren't directly related to the deceased (a.k.a. next of kin), this could also mean you lose your inheritance.

4. It’s important to file any necessary state tax returns on behalf of the deceased or estate by the following tax season in Georgia. If you don’t, you could owe penalties and interest. This also includes any necessary federal tax returns such as Forms 1040, 1041, or even a Form 706 estate tax return.

5. If a house in the State of Georgia is left empty (or abandoned) for a while, insurance can get dicey. For example, if the house burns down and no one has been there for a year, an insurance company may get out of paying your claim.

If you’re not using Atticus to get specific forms, deadlines, and timelines for Georgia probate, then try and stay as organized as possible, pay close attention to the dates mentioned in any correspondence you have with the State’s government officials, call the local Georgia probate clerk or court for exact answers regarding Form GPCSF 19, and when in doubt— consult a qualified trust & estates lawyer for that area.

Petition To Compromise Doubtful Claim Of Minor/adult Ward is one of the many probate court forms available for download through Atticus.

It may also be available through some Georgia probate court sites, such as . In order to access the latest version, be updated with any revisions, and get full instructions on how to complete each form, check out the Atticus Probate & Estate Settlement software or consider hiring a qualified legal expert locally within Georgia.

While Atticus automatically provides the latest forms, be sure to choose the correct version of Form GPCSF 19 - Petition To Compromise Doubtful Claim Of Minor/adult Ward f using any other site or resource in order to avoid having to re-complete the form process and/or make another trip to the Georgia probate court office.

Petition To Compromise Doubtful Claim Of Minor/adult Ward is a .pdf, so opening it should be as simple as clicking “View Form” from within the Atticus app or by clicking the appropriate link found on any Georgia-provided government platform. Once you’ve opened the form, you should be able to directly edit the form before saving or printing.

Here’s the text, verbatim, that is found on Georgia Form GPCSF 19 - Petition To Compromise Doubtful Claim Of Minor/adult Ward. You can use this to get an idea of the context of the form and what type of information is needed.

PETITION TO COMPROMISE DOUBTFUL CLAIM OF MINOR/ADULT WARD INSTRUCTIONS I. Specific Instructions 1. This form is to be used when petitioning the Probate Court for authorization to compromise a doubtful personal injury claim of a minor pursuant to O.C.G.A. § 29-3- 3. 2. The term “gross settlement” is defined in O.C.G.A. § 29-3- 3. 3. This form can also be used to compromise a doubtful personal injury claim of an adult ward pursuant to O.C.G.A. § 29-5- 23 (c) (5); however, some modifications may be necessary. 4. This form must be modified when a covenant not to sue, as opposed to a release from liability, will be executed by the natural guardian or conservator. 5. This form may also be used when compromising claims other than personal injury claims pursuant to O.C.G.A. § 29-3- 3, provided appropriate changes are made in the form. 6. If there is a legally qualified Conservator, it may not be necessary to file a separate Petition to Encroach on Corpus concerning the expenses listed in Paragraph 17 of this form. However, the Court may direct that a separate encroachment petition be filed, in which case the prayers listed on Page 8 and the provisions of the Order should be modified. 7. The full particulars as to the facts that give rise to the cause of action should be listed in the Petition. 8. The amount of assets the Minor/Adult Ward has prior to the settlement or action addressed in this Petition must be listed. 9. If an annuity or structured settlement is being purchased for the Minor/Adult Ward, the terms of the annuity must be specified on the form titled “Disclosure of Structured Settlement” and signed by the parties and the insurance company that is funding the annuity. 10. When a structured settlement is to be purchased for the Minor/Adult Ward, the terms of who is responsible for funding the annuity, including terms and time limits for the purchase and/or funding, should be included in the Final Order. 11. O.C.G.A. § 53-11-2 provides that a party to a probate proceeding who is not sui juris must be represented by a guardian provided that the Court may appoint a guardian ad litem or determine that the natural guardian, guardian, conservator or testamentary GPCSF 19 [1 ] Eff. July 2015 guardian has no conflict and may serve. Should a guardian ad litem be necessary because a party is not sui juris, use Supplement 1. [Also see O.C.G.A. § 29-3- 22 (c) (5).] 12. Use Supplement 2 if the Court determines it is appropriate to appoint a special process server. 13. Use Supplement 3 when an additional certificate of service is necessary. 14. Exhibits should be labeled at the bottom of each exhibit as Exhibit “A,” Exhibit “B,” etc. in consecutive order. The corresponding letter of each exhibit should be inserted into the appropriate place in the form. II. General Instructions General instructions applicable to all Georgia Probate Court Standard Forms are available in each Probate Court, labeled GPCSF 1. GPCSF 19 [2 ] Eff. July 2015 IN THE PROBATE COURT COUNTY OF _______________________ STATE OF GEORGIA IN RE: ESTATE OF ) ) ESTATE NO. _________________ ____________________________________, ) MINOR/ADULT WARD ) PETITION TO COMPROMISE DOUBTFUL CLAIM OF MINOR OR ADULT WARD The Petition of , [Full name of Petitioner(s)] First Middle Last whose physical address(es) is/are , Street City County State Zip Code and mailing address(es) is/are , Street City County State Zip Code shows the Court the following: 1. The Minor/Adult Ward: [list full name and address of Minor/Adult Ward] ______________________________________________________________________________ [Full name and address of Minor/Adult Ward]First Middle Last ______________________________________________________________________________ [Full physical address] Street City County State Zip Code whose birth date is _________________________ and is ____________ years old, received personal injuries as a result of the following occurrence: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. The Minor/Adult Ward currently has cash and/or personal property in the amount of $ ___________________________ and will receive funds of $ ________________________ as a result of this settlement. Petitioner(s) currently has/have a bond on file, to cover the cash/personal property of this Minor/Adult Ward in the amount of $ ______________________. Petitioner(s) is/are prepared to file a bond or rider for a total of $ ____________________ to secure the amount of the personal property currently in the Minor’s/Adult Ward’s estate plus the proceeds of this compromised claim. GPCSF 19 [1 ] Eff. July 2015 [Complete either Paragraph 3 or Paragraph 4] 3. There is no conservator for the Minor/Adult Ward, and: [Initial one] _____ The Petitioner(s) herein has/have filed a Petition to be appointed conservator(s) along with the filing of this Petition. _____ The Petitioner(s) do(es) not seek to be appointed as conservator(s), but another person, __________________________________, will file a Petition for appointment as conservator at the same time or shortly after this Petition is filed. _____ The Petitioner(s) allege(s) that the establishment of a conservatorship is not necessary because: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. [Initial if applicable] _____ The Petitioner(s) is/are the Conservator for the Minor/Adult Ward. Copies of the Order of Appointment and Letters of Conservatorship are attached hereto as Exhibit “____.” _____ ____________________________ is/are the Conservator(s) for the Minor/Adult Ward. Copies of the Order of Appointment and Letters of Conservatorship are attached hereto as Exhibit “____.” 5. The claim being settled by this Petition is against ________________________________ by virtue of an incident occurring on or about ________________________________, 20_____. List the full particulars giving rise to the cause of action by the Minor/Adult Ward: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ GPCSF 19 [2 ] Eff. July 2015 6. The entities against whom the Minor/Adult Ward has a claim that are not part of this settlement are: [List such adverse part(y)(ies) below] ______________________________________________________________________________ [Full name] First Middle Last ______________________________________________________________________________ [Full physical address] Street City County State Zip Code ______________________________________________________________________________ [Full name] First Middle Last ______________________________________________________________________________ [Full physical address] Street City County State Zip Code 7. [Initial one] _____ A lawsuit has not been filed. _____ A lawsuit has been filed. A copy of the Complaint is attached as Exhibit “____.” _____ A lawsuit was filed and settled. A copy of the Settlement Agreement and Order of the trial court approving the same are attached hereto as Exhibit “____.” 8. [Initial one] _____ An accident report was not made. _____ An accident report was made and is attached hereto as Exhibit ____.” If none, state why an accident report was not made. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 9. [Initial all applicable] _____ a. The action did not arise from an alleged wrongful death of a parent. _____ b. The action arose from an alleged wrongful death of a parent, and a personal representative has not been appointed for such parent. _____ c. The action arose from an alleged wrongful death of a parent and a Personal Representative has been appointed for the parent, a copy of the (Letters Testamentary) (Letters of Administration) (Letters of Administration with Will Annexed) is attached as Exhibit “____,” and his/her/their name(s) and address(es) is/are as follows: GPCSF 19 [3 ] Eff. July 2015 ______________________________________________________________________________ [Full name(s) of Personal Representative(s)]First Middle Last ______________________________________________________________________________ [Full physical address] Street City County State Zip Code 10. The Minor/Adult Ward sustained the following injuries: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 11. The Minor/Adult Ward has been treated by: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 12. The Minor's/ Adult Ward’s physical, mental, and emotional condition, as evidenced by the statement of the treating doctor attached as Exhibit “____,” has returned to the condition of said Minor/Adult Ward prior to such incident, except for: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 13. The following is a list of all medical expenses and other special damages incurred to date as a result of the injur(y)(ies) to said Minor/Adult Ward. (Documentation of which is attached as Exhibit “____.”): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ GPCSF 19 [4 ] Eff. July 2015 14. The following is a list of all medical expenses and other special damages expected to be incurred in the future as a result of the injury to said Minor/Adult Ward as evidenced by the statement of the treating doctor or doctors attached as Exhibit “____.” ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 15. Medical expenses have been paid as follows: a. $ __________________________ by ___________________________________’s medical payment reimbursement insurance coverage. $ __________________________ of such coverage remains and will not be released by this settlement. b. $ __________________________ from any group or private insurance sources. c. $ __________________________ as a result of workers’ compensation coverage. d. $ __________________________ from any other source. [List the name(s) of such source(s):] __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 16. [Initial as many as are applicable] _____ a. The Petitioner(s) has/have made a full investigation into the facts and circumstances surrounding the incident. _____ b. It is uncertain or doubtful that more than the amount offered in the settlement could be recovered. _____ c. The opposing part(y)(ies) contend(s) that he/she/they is/are not responsible or liable in any way for the injuries that might have been sustained by said Minor/Adult Ward. GPCSF 19 [5 ] Eff. July 2015 If you did not initial a., b. or c., explain: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 17. Petitioner(s) and __________________________________________________________ have agreed upon a compromised settlement of all claims, which Petitioner(s) believe(s) to be made in good faith, is fair, reasonable, and just under the circumstances; and in the best interest of the Minor/Adult Ward, upon the terms and conditions set forth below: a. Gross Settlement [Total amount of the settlement proceeds to be received by the Minor/Adult Ward]: $ _________ b. Expenses: i. Attorney’s fees: $ _________ ii. Expenses of litigation: $ _________ iii. Medical expenses now due: $ _________ iv. Other* [explain below]: $ _________ Total Expenses $ _________ c. Cost of Annuity, if any: $ _________ d. Net Amount to Conservatorship [Gross Settlement less Expenses and Cost of Annuity, if any]: $ _________ *Further explanation, if necessary: [ required if “Other,” (b) (iv), is listed] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ GPCSF 19 [6 ] Eff. July 2015 18. The following is a description and explanation of any amounts being paid to persons other than for the benefit of the Minor/Adult Ward as a result of the injuries to said Minor/Adult Ward [Note: any amounts listed should have documentation of those claims attached as Exhibit “____.”]: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 19. [Initial and complete all that apply] _____ a. The adverse part(y)(ies) is/are covered by the following insurance company(ies) [provide full name(s) and address(es) for all insurance companies involved in the settlement]: ______________________________________________________________________________ [Full name of insurance company] ______________________________________________________________________________ [Full name of agent, if known] First Middle Last ______________________________________________________________________________ [Full physical address] Street City County State Zip Code ______________________________________________________________________________ [Full mailing address] Street City County State Zip Code _____ b. The adverse part(y’s)(ies’) policy limits of insurance are $ _____________________. _____ c. Uninsured motorist coverage held by _______________________________________ is contributing $ __________________________________ to the settlement. 20. [Initial if applicable] _____ a. It appears that the claim is worth more than the insurance policy limits, but the Petitioner(s) investigated the assets of the part(y)(ies) being released as part of this settlement and offers the following explanation of why this settlement is appropriate and why any party should be released: GPCSF 19 [7 ] Eff. July 2015 ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 21. [Initial and complete if applicable] The Petitioner(s) employed an attorney to represent the Petitioner(s) in the prosecution of the Minor’s/Adult Ward’s claim, as follows: ______________________________________________________________________________ [Full name] First Middle Last ______________________________________________________________________________ [Full physical address] Street City County State Zip Code ______________________________________________________________________________ [Full physical address] Street City County State Zip Code 22. [Initial and complete if applicable] _____ a. The Petitioner(s) has/have agreed to pay the attorney’s fees and expenses of litigation as follows: Detail the percentage rate for calculating fees or flat rate as well as total expenses to be paid to attorneys. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____ b. The amount agreed to is listed in Paragraph 17(b)(i) and (ii) above and represents ________________ % of the total settlement. 23. [Initial and complete if applicable] _____ Petitioner(s) seek(s) to direct settlement proceeds into a structured settlement and the Disclosures Regarding Structured Settlement are attached hereto as Exhibit “____.” GPCSF 19 [8 ] Eff. July 2015 24. Additional Data: [Where full particulars are lacking, state here the reasons for any such omission.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ WHEREFORE, Petitioner(s) pray(s) for an order approving and allowing Petitioner(s) to accept said offer to compromise and settle upon the terms set forth above; that Petitioner(s) be authorized to consummate the settlement and execute any and all agreements, receipts, releases, and other documents necessary or proper to effect said settlement; and that Petitioner(s) be authorized to pay from the gross settlement amount all fees and expenses described in Paragraph 17 above. Signature of First Petitioner Signature of Second Petitioner, if any Printed Name Printed Name Address Address Telephone Number Telephone Number Signature of Attorney Printed Name of Attorney Address Telephone Number State Bar # GPCSF 19 [9 ] Eff. July 2015 VERIFICATION GEORGIA, _______________________ COUNTY Personally appeared before me the undersigned Petitioner(s) who, after being duly sworn, state(s) that the facts set forth in the foregoing Petition and the attached Exhibit(s) are true and correct. Sworn to and subscribed before me this _____ day of __________, 20___. ___________________________________ NOTARY/CLERK OF PROBATE COURT My Commission Expires ______________ ____________________________________ Signature of First Petitioner ____________________________________ Printed Name of First Petitioner Sworn to and subscribed before me this _____ day of __________, 20___. ___________________________________ NOTARY/CLERK OF PROBATE COURT My Commission Expires ______________ ____________________________________ Signature of Second Petitioner, if any ____________________________________ Printed Name of Second Petitioner, if any GPCSF 19 [10] Eff. July 2015 DISCLOSURES REGARDING STRUCTURED SETTLEMENT 1. Total Cost of Structured Settlement: __________________________________________ 2. This Structured Settlement is being funded by: __________________________________ ________________________________________________________________________ 3. This Structured Settlement is purchased through the following: ________________________________________________________________________ [Full name of insurance company providing annuity] ________________________________________________________________________ [List full address of company] Street City County State Zip 4. Annuity Terms: a. Total payout over life of annuity: ______________________________________ b. Amount GUARANTEED: ____________________________________________ c. Do payments terminate at death: _______________________________________ d. Amount of payment: ________________________________________________ i. If periodic 1. State period [e.g., monthly] _______________________________ 2. Beginning date:_____________ Ending date: ________________ ii. If lump sum distributions at date certain, please list: 1. $ _______________________ date ____________________ 2. $ _______________________ date ____________________ 3. $ _______________________ date ____________________ NOTE: THE ESTATE OF THE MINOR/ADULT WARD MUST BE THE NAMED BENEFICIARY TO RECEIVE ANY GUARANTEED PAYMENTS THAT WILL BE PAID AFTER THE DEATH OF THE MINOR/ADULT WARD. The Petitioner(s) may NOT name himself/herself/themselves as the beneficiary(ies) of any assets paid after the death of the Minor/Adult Ward without Court approval. 5. List any amounts attorneys will receive AFTER INITIAL SETTLEMENT, if any: a. ______________________ date ____________________ b. ______________________ date ____________________ IN THE PROBATE COURT COUNTY OF _______________________ STATE OF GEORGIA IN RE: ESTATE OF ) ) ESTATE NO. __________________ ____________________________________, ) MINOR/ADULT WARD ) GPCSF 19 [11] Eff. July 2015 6. Name, address, and telephone number of company underwriting the annuity: Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone Number: _______________________________________________________ 7. The company is rated through ________________________ and has a rating of _______. 8. The Petitioner(s) has/have made an investigation into the facts of this case and the circumstances of the Minor/Adult Ward and determined that the structured settlement is in the best interest of the adult Minor/Adult Ward. Signature of First Petitioner Signature of Second Petitioner, if any Printed Name Printed Name Address Address Telephone Number Telephone Number Signature of agent of annuity provider Typed/printed name of agent Address Telephone number Exhibit “____” GPCSF 19 [12] Eff. July 2015 IN THE PROBATE COURT COUNTY OF _______________________ STATE OF GEORGIA IN RE: ESTATE OF ) ) ESTATE NO. _________________ ____________________________________, ) MINOR/ADULT WARD ) ORDER AUTHORIZING SETTLEMENT The foregoing Petition was read and considered, and it appears upon hearing based on the record and facts set out in the Petition and introduced at trial that said settlement is fair, reasonable, and just, that the same is made in good faith and will be in the best interest of the said Minor/Adult Ward. [Strike the portions of this Order that are not applicable to this case] (No objection to the proposed compromised claim being raised by the guardian ad litem.) (Objections were filed by the guardian ad litem or an interested party, but have now been resolved.) [Insert any other relevant procedural history here] IT IS HEREBY ORDERED AND ADJUDGED that Petitioner(s) be, and is/are, hereby authorized to consummate said settlement as prayed in said Petition and to execute any and all agreements, receipts, releases, or other documents necessary or proper to effect such settlement and that such agreements, receipts, releases, or other documents shall constitute the full, final, and complete settlement of any and all actions, causes of action, claims, or demands which the above-named Minor/Adult Ward may have against those parties to the settlement named in the Petition as fully and completely as if said Minor/Adult Ward had executed said agreements, receipts, releases, or other documents individually. IT IS FURTHER ORDERED that the Petitioner(s) is/are hereby authorized to pay all fees and expenses as shown below: a. Gross Settlement [Total amount of the settlement proceeds to be received by the Minor/Adult Ward]: $ _________ b. Expenses: i. Attorney’s fees: $ _________ ii. Expenses of litigation: $ _________ iii. Medical expenses now due: $ _________ iv. Other: $ _________ Total Expenses $ _________ c. Cost of Annuity, if any: $ _________ d. Net Amount to Conservatorship [Gross Settlement less Expenses and Cost of Annuity, if any]: $ _________ GPCSF 19 [13] Eff. July 2015 [Initial those which are applicable] _____ IT IS FURTHER ORDERED that the Minor’s/Adult Ward’s award is hereby paid to the court appointed Conservator(s). and/or _____ IT IS FURTHER ORDERED that a conservator is not necessary because the “net” award is under $15,000.00 and therefore will be paid to the Natural Guardian(s) of the above- named Minor/Adult Ward. and/or _____ IT IS FURTHER ORDERED that an annuity (has been) (will be) purchased. Attorney _____________________________________________________________________, representing ___________________________________________________________________, has stated in open court that all funds owed to the Minor/Adult Ward will be held in the escrow account of ____________________________________________________________________, until the purchase of the annuity and that the money will be disbursed from the escrow account to purchase the annuity and will not be given over to the Petitioner(s). The attorney will confirm disbursement once the annuity is funded and file notice with this Court and the guardian ad litem. The appointed guardian ad litem will report to the Court once he/she has confirmed the annuity was purchased. and/or _____ IT IS FURTHER ORDERED that an annuity (has been) (will be) purchased by the insurance company liable for the Minor’s/Adult Ward’s claim(s). The insurance company will also pay the other claims above directly including the attorney’s fees, expenses of litigation and/or medical expenses. and _____ IT IS FURTHER ORDERED that all terms of this Order shall be completed within _________ days of this Order. SO ORDERED this _____ day of __________________, 20____. __________________________________________ Judge of the Probate Court GPCSF 19 [14] Eff. July 2015