Orange — Minor's Compromise

Source: https://www.occourts.org/system/files/selfhelp/shc-pb-07.pdf

SUPERIOR COURT OF CALIFORNIA Self-Help Services COUNTY OF ORANGE www.occourts.org/self-help

MINOR'S COMPROMISE

SELF-HELP FORM PACKET

Attention

New Probate Court and In-Person Location: Costa Mesa Justice Complex 3390 Harbor Boulevard Costa Mesa, CA 92626

SHC-PB-07 (Rev. 05/01/2023)

Self-Help Services can review your completed forms before you file them with the Court. To request review of your completed forms:

1. Complete the attached forms in black ink.
2. Scan your completed forms and save as a single PDF file.
3. Go to www.occourts.org/self-help (click the blue button labeled Click Here to Contact Self-Help Services), attach the PDF, and complete the online request form. Make sure to select PROBATE as the case type on the form.

www.occourts.org/self-help

MC-350 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO. : EMAIL ADDRESS: ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE STREET ADDRESS: 3390 Harbor Boulevard MAILING ADDRESS: 3390 Harbor Boulevard CITY AND ZIP CODE: Costa Mesa 92626 BRANCH NAME: Costa Mesa Justice Complex CASE NAME: CASE NUMBER:

HEARING DATE:
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF DEPT.: TIME:
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

NOTICE TO PETITIONER

Except as noted below, you must use this form to request court approval of (1) the compromise of a minor's disputed claim, (2) the compromise or settlement of a pending action or proceeding to which a minor or a person with a disability (including a conservatee) is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600–3613.) Both you and the minor or person with a disability must attend the hearing on this petition unless the court dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and the presentation of other evidence relating to the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court has authority to consider a request for expedited approval without a hearing of the compromise of certain claims or actions or the disposition of the proceeds of certain judgments. To determine whether your claim, action, or judgment qualifies, see Cal. Rules of Court, rule 7.950.5. If you want to request expedited consideration, you must use form MC-350EX.

1. Petitioner (name or pseudonym*): is the (check all boxes that apply): Parent Guardian ad litem* Guardian Conservator Other (specify relationship): of the claimant identified in item 2. (*Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ. Proc., § 372.5.))

2. Claimant (name): a. Address: b. Date of birth: c. Age: d. Minor or Person with a disability (If the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.)) e. Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or judgment. f. Does not have a conservator of the estate.

3. Claim The claim of the minor or adult person with a disability (check one): a. Is not the subject of a pending action or proceeding. (Complete items 4–23.) b. Is the subject of a pending action or proceeding that will be compromised or settled without a trial. (Complete items 4–23.) Name of court: Case no.: Trial date: c. Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the defendants named below in the amount (excluding interest and costs) of (specify total): $ . Defendants (names:

   Additional defendants listed on Attachment 3.

   The judgment was filed on (date): (Attach a copy of the (proposed) judgment as Attachment 3c and complete items 12–23.)

Form Adopted for Alternative Mandatory Use Code of Civil Procedure, § 372; Instead of Form MC-350EX PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Probate Code, §§ 3500, 3600–3613; Judicial Council of California MC-350 [Rev. January 1, 2021] OR ACTION OR DISPOSITION OF PROCEEDS OF Cal. Rules of Court,7.101, rules7.950–7.9523.1384, JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www.courts.ca.gov

MC-350 CASE NAME: CASE NUMBER:

4. Incident or accident The incident or accident occurred as follows: a. Date: Time: b. Place: c. Persons involved (names):

   Continued on Attachment 4.

5. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened):

   Continued on Attachment 5.

6. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe):

   Continued on Attachment 6.

7. Treatment The claimant received the following care and treatment for the injuries described in item 6 (describe):

   Continued on Attachment 7.

8. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 8. A new report is not necessary if a previous report accurately describes the claimant's current condition.) a. The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent injuries. b. The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): Continued on Attachment 8b. c. The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms): Continued on Attachment 8c.

MC-350 [Rev. January 1, 2021] Page 2 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

9. Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is approved by the court and consummated, the claimant will never be able to recover any more compensation from the settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear.

10. Amount and terms of settlement To settle the claim in 3a or 3b, the defendants named below have offered to pay the following amounts to the claimant: a. The total amount offered by all defendants named below is (specify): $ b. The defendants and amounts offered by each are as follows (specify): Defendants (names) Amounts $ $ $ $ Defendants and amounts offered continued on Attachment 10b. c. The terms of settlement are as follows. (If the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.)

    Continued on Attachment 10c.

11. Settlement payments to others a. No defendant named in item 10b has offered to pay money to any person or persons other than the claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury.

b. To settle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants named in item 10b have also offered to pay money to a person or persons other than claimant. (1) The total amount offered by all defendants to others is (specify): $ (2) Petitioner does not have has a claim against the recovery of the claimant (other than for reimbursement of fees or expenses paid by petitioner and listed under item 14). (If you answered "has," explain in Attachment 11b(2) the circumstances and the effect your claim has on the proposed compromise of the claim described in this petition.) (3) Petitioner is not is a plaintiff in the same action with the claimant. (If you answered "is," explain in Attachment 11b(3) the circumstances and the effect your claim and its disposition has on the proposed compromise of the claim or action described in this petition.) (4) Petitioner would receive money under the proposed settlement. (5) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts $ $ $ $ Additional plaintiffs or claimants and amounts are listed on Attachment 11b(5). (6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified in Attachment 11b(6).

MC-350 [Rev. January 1, 2021] Page 3 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

12. The claimant's medical expenses—including medical expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—to be paid or reimbursed from proceeds of settlement or judgment a. Totals (1) Total medical expenses before any reductions: $ (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ ) (3) Total of negotiated, contractual, or statutory reductions, if any: ($ ) (4) Total medical expenses to be paid or reimbursed from the proceeds: $ (5) Total amount of statutory or contractual liens, if any: $

    b. Medical expenses were paid and are to be reimbursed from the proceeds as follows:

    (1) Paid by petitioner in the amount of: $

    (2) Paid by private health insurance or a self-funded plan under:
    (a) An Employee Retirement Income Security Act (ERISA) insured plan.
    (b) An ERISA self-funded plan.
    (c) A Non-ERISA insured plan.
    (d) A Non-ERISA self-funded plan.
    (e) Amount paid by plan: $
    (f) Amount of reimbursement to the plan from the proceeds of the settlement or judgment:
    (i) No reimbursement is requested by the plan.
    (ii) Reimbursement is to be made to the plan, and:
    (A) There is a contractual reduction of: ($ ),
    (B) There is a negotiated reduction of: ($ ),
    (C) No reduction has been agreed to,
    for a total reimbursement to the plan, in full satisfaction of its lien rights, in the amount of: $

    (3) Paid by Medicare in the amount of: $
    less the statutory reduction in the amount of: ($ )
    for a total reimbursement to Medicare in the amount of: $
    (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 12b(3).)

    (4) Paid by Medi-Cal in the amount of: $
    (a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code,
    § 14124.73.) A copy of the notice and proof of delivery:
    is attached was filed in this case on (date): .
    (b) Notice of this claim or action has not been given to the Director of Health Care Services. (Explain why notice has
    not been given in Attachment 12b(4)(b).)
    (c) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of:
    $
    (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 12b(4)(c).)
    (d) Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and
    (check one):
    (i) Is filing a motion seeking a reduction of the lien concurrently with this petition.
    (ii) Requests that the court reserve jurisdiction over this issue.
    The amount of the lien in dispute is: $

    (5) (a) (i) There are no statutory or contractual liens for payment of claimant's medical expenses.
    (ii) There are one or more statutory or contractual liens of medical service providers for payment of claimant's
    medical expenses. The total amount claimed under these liens is: $
    In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $
    (Provide requested information for each lienholder and other specified medical service providers on next page.)

MC-350 [Rev. January 1, 2021] Page 4 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

12. Claimant's medical expenses (continued) b. (5) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows: (i) (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ ) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $ (ii) (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ ) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $ (iii) (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ ) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $ Continued on Attachment 12b(5). (Provide information about additional providers in the above format, including providers paid or to be paid by petitioner, for which payment reimbursement is requested in item 12b(1), above. You may use form MC-350(A-12b(5)) for this purpose.)

13. Claimant's attorney's fees and all other expenses (except for medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment a. Total amount of attorney's fees for which court approval is requested: $ (If fees are requested, attach as Attachment 13a a declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Respond to item 17a(2) on page 7 and attach a copy of any written attorney fee agreement as Attachment 17a.) b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts $ $ $ $ $ $ $ $ Continued on Attachment 13b. Total: $

MC-350 [Rev. January 1, 2021] Page 5 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

14. Reimbursement of fees and expenses paid by petitioner a. Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested. b. Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's fees and expenses for which reimbursement is requested. (1) Medical expenses listed in item 12: $ (2) Attorney's fees included in the total fee amount shown in item 13a: $ (3) Other expenses included in the total shown in item 13b: $ Total: $

    (Attach proofs of the fees and expenses incurred and the payments made or obligations to pay incurred, e.g., bills or invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.)

15. Net balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment of all requested fees and expenses is: $

16. Summary a. Gross amount of proceeds of settlement or judgment: $ b. Medical expenses to be paid from proceeds of settlement or judgment: $ c. Attorney's fees to be paid from proceeds of settlement or judgment: $ d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ e. Total fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): ($ ) f. Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): $

MC-350 [Rev. January 1, 2021] Page 6 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

17. Information about attorney representing or assisting petitioner

    a. (1) Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the claim asserted. (Skip the rest of item 17 and go to item 18.) (2) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim asserted. Petitioner and the attorney do not do have an agreement for services provided in connection with the claim giving rise to this petition. (If you answered ''do,'' attach a copy of the agreement as Attachment 17a, and complete items 17b–17f.)

    b. The attorney who has represented or assisted petitioner is (name):

    (1) State Bar number:
    (2) Law firm:
    (3) Address:

    (4) Telephone number: (5) Email:

    c. The attorney has not has received attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition. (If you answered ''has,'' identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment): From whom (names) Amounts Dates $ $ $ $ $ Continued on Attachment 17c.

    d. The attorney did not did become concerned with this matter, directly or indirectly, at the instance of a party against whom the claim is asserted or a party's insurance carrier. (If you answered ''did," explain the circumstances in Attachment 17d.)

    e. The attorney is not is representing or employed by any other party or any insurance carrier involved in the matter. (If you answered "is," identify the party or carrier and explain the relationship in Attachment 17e.)

    f. The attorney does not does expect to receive attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition. (If you answered ''does,'' identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment): From whom (names) Amounts Expected dates $ $ $ $ $ Continued on Attachment 17f.

MC-350 [Rev. January 1, 2021] Page 7 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

18. Disposition of balance for claimant (check either a or b, then check each option requested and enter amount(s)): a. There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability filed in (name of court): Case no.: (1) Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(1). (2) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ of the money or other property to be paid or delivered under 18a(1) in insured accounts in one or more financial institutions in this state or with a trust company, subject to withdrawal only on authorization of the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 18a(2). (3) Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply): (a) $ to be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 18a(3)(a). (b) $ to be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18a(3)(b). (c) $ to be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are specified in Attachment 18a(3)(c). (d) $ to be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 18a(3) (d). A copy of the (proposed) judgment is attached as Attachment 3c. (e) $ to be transferred to the trustee of a special needs trust under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the property to be transferred are specified in Attachment 18a(3)(e). b. There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (1) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed and $ of money or other property be paid or delivered to the person so appointed. The money or other property are specified in Attachment 18b(1). (2) $ be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 18b(2). (3) $ be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18b(3). (4) $ be paid or transferred to the trustee of a special needs trust established under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the money or other property to be paid or transferred are specified in Attachment 18b(4). (5) $ be paid or delivered to a parent of the minor, without bond, on the terms and under the conditions specified in Probate Code sections 3401–3402. The name and address of the parent and the money or other property to be delivered are specified in Attachment 18b(5). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) (6) $ be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 18b(6).

MC-350 [Rev. January 1, 2021] Page 8 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

18. Disposition of balance of proceeds of settlement or judgment (continued) b. There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (7) $ be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age, and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7). A copy of the (proposed) judgment is attached as Attachment 3c. (8) $ of money be held on any conditions the court determines are in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not exceed $20,000.) (9) $ of property other than money be held on the conditions that the court determines to be in the best interest of the minor or adult person with a disability. The proposed conditions and the property are specified in Attachment 18b(9). (10) $ be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h). (11) $ be paid or delivered to the adult person with a disability. The money or other property is specified in Attachment 18b(11).

19. Statutory liens for special needs trust Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Probate Code section 3604, if any, will be satisfied):

    Continued on Attachment 19.

20. Additional orders

    Petitioner requests the following additional orders (specify and explain):

    Continued on Attachment 20.

MC-350 [Rev. January 1, 2021] Page 9 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350 CASE NAME: CASE NUMBER:

21. I, the claimant named in item 2, consent to the order or judgment requested in this petition.

    (Required if the claimant is an adult with a disability who has the capacity, under Probate Code section 812, to consent to the order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.))

Date:

(TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT)

22. Petitioner recommends approval of the proposed compromise, settlement, or disposition of judgment proceeds to the court as fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise, settlement, or disposition and make any other orders that are just and reasonable.

23. Number of pages attached:

Date:

(TYPE OR PRINT NAME OF ATTORNEY) (SIGNATURE OF ATTORNEY)

I declare under penalty of perjury under the laws of the State of California that the foregoing information on this form and all attachments is true and correct.

Date:

(TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER)

MC-350 [Rev. January 1, 2021] Page 10 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form

MC-350(A-12b(5)) CASE NAME: CASE NUMBER:

ADDITIONAL MEDICAL SERVICE PROVIDERS ATTACHMENT TO PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT

If you are using form MC-350 to petition for court approval of the compromise of a claim or action or the disposition of the proceeds of a judgment for a minor or person with a disability, you must provide complete information, in item 12b(5) of form MC-350, about any medical service providers that (1) have liens for payment of charges for medical services provided to the minor or person with a disability or (2) you paid (or will pay from the proceeds), for which payment you request reimbursement from the proceeds of the compromise or judgment. If you don't have enough room on form MC-350, you may use one or more copies of this form to provide the required information about additional medical service providers.

Attachment 12b(5) to form MC-350

12. b. (5) (b) Each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows: (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ ) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $ (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ ) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $ (A) Provider (name): (B) Address:

(C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ ) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $

(A) Provider (name):
(B) Address:

(C) Amount charged: $
(D) Amount paid (whether or not by insurance): ($ )
(E) Negotiated reduction, if any: ($ )
(F) Amount to be paid from proceeds of settlement or judgment: $

Page of attached pages

Form Approved for Optional Use Code of Civil Procedure, § 372 et seq.; Judicial Council of California ADDITIONAL MEDICAL SERVICE PROVIDERS ATTACHMENT Probate Code, §§ 3500, 3600–3613; MC-350(A-12b(5)) [Rev. January 1, 2021] TO PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR Cal. Rules of Court, ruleswww.courts.ca.gov3.1384, 7.950 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT

MC-351 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE STREET ADDRESS: 3390 Harbor Boulevard MAILING ADDRESS: 3390 Harbor Boulevard CITY AND ZIP CODE: Costa Mesa 92626 BRANCH NAME: Costa Mesa Justice Complex CASE NAME:

CASE NUMBER:
ORDER APPROVING COMPROMISE OF CLAIM OR ACTION
OR DISPOSITION OF PROCEEDS OF JUDGMENT HEARING DATE, IF ANY: DEPT.:
FOR MINOR OR PERSON WITH A DISABILITY

1. Hearing a. No hearing was held. The matter is eligible for expedited approval under rule 7.950.5 of the California Rules of Court. b. A hearing was held: Date: Time: Dept.: c. Judicial officer:

2. Petitioner (name or pseudonym*): is the (check all relationships or representative capacities that apply): parent guardian ad litem* guardian conservator other (specify): of the claimant named in item 3. Petitioner has requested approval of the compromise or settlement of a disputed claim or pending action or the disposition of the proceeds of a judgment for a minor or a person with a disability. (*Petitioner was appointed guardian ad litem under a pseudonym. (See Code Civ. Proc., § 372.5.))

3. Claimant (name): a. is a minor. b. is a "person with a disability" within the meaning of Probate Code section 3603 who is: (1) An adult. Claimant's date of birth is (specify): (2) A minor described in Probate Code section 3603(b)(3).

4. Defendant The claim or action to be compromised or settled is asserted, or the judgment is entered, against (name of settling or judgment defendant or defendants (the "payer")):

THE COURT FINDS 5. Notice has been given as required by law.

6. a. The claimant is an adult who has the capacity to consent to this order within the meaning of Probate Code section 812 and does not have a conservator of the estate. The claimant has given express consent to this order. b. The claimant's consent to this order is not required because the claimant is a minor, a conservatee, or a person who lacks the capacity to consent to the order within the meaning of Probate Code section 812.

Form Adopted for Mandatory Judicial Council of California Use ORDER APPROVING COMPROMISE OF CLAIM OR ACTION ProbateCodeCode,of Civil§§ 3500,Procedure,3600–3613;§ 372; MC-351 [Rev. January 1, 2021] OR DISPOSITION OF PROCEEDS OF JUDGMENT Cal. Rules of Court, ruleswww.courts.ca.gov3.1384, 7.953 FOR MINOR OR PERSON WITH A DISABILITY

MC-351 CASE NAME: CASE NUMBER:

THE COURT ORDERS 6. The petition is granted and the proposed compromise or settlement, or the proposed disposition of the proceeds of the judgment, is approved. The gross amount or value of the settlement or judgment in favor of claimant is: $ .

7. Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under Welfare and Institutions Code section 14124.76. The amount shown payable to the Department of Health Care Services in item 8a(4) of this order is the full amount of the lien claimed by the department but is subject to reduction on further order of the court upon determination of the claim for reduction.

8. The payer must disburse the proceeds of the settlement or judgment approved by this order in the following manner: a. Payment of fees and expenses Fees and expenses shall be paid by one or more checks or drafts drawn payable to the order of the petitioner and the petitioner's attorney, if any, or directly to third parties entitled to receive payment identified in this order for the following items of expense or damage, which are hereby authorized to be paid out of the proceeds of the settlement or judgment:

   (1) Attorney's fees in the total amount of: $ payable to (specify):

   (2) Reimbursement for medical and all other expenses paid by the petitioner or the petitioner's
   attorney in the total amount of: $

   (3) Medical, hospital, ambulance, nursing, and other similar expenses payable directly to
   providers as follows, in the total amount of: $
   (a) Payee (name):
   (i) address:

   (ii) Amount: $
   (b) Payee (name):
   (i) address:

   (ii) Amount: $
   Continued on Attachment 8a(3). (Provide information about additional payees in the above format.)

   (4) Other authorized disbursements payable directly to third parties in the total amount of: $
   (Describe and state the amount of each item and provide the name and address of each payee):

   Continued on Attachment 8a(4).

   (5) Total allowance for fees and expenses from the settlement or judgment: $

MC-351 [Rev. January 1, 2021] ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Page 2 of 4 OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-351 CASE NAME: CASE NUMBER:

8. b. Balance for claimant The balance of the settlement or judgment available for claimant after payment of all allowed fees and expenses is: $ The balance shall be disbursed as follows: (1) By one or more checks or drafts in the total amount of (specify): $ drawn payable to the order of the petitioner in the petitioner's representative capacity. Each check or draft must bear an endorsement on the face or reverse that it is for deposit in one or more interest-bearing, federally insured accounts in the name of the petitioner in the petitioner's representative capacity. No withdrawals may be made from these accounts (''blocked accounts") except as provided in the Order to Deposit Funds in Blocked Account (form MC-355) signed at the same time as this order. (2) By the following method(s) (describe each method, including the amount to be disbursed by each): Continued on Attachment 8b(2). (3) If money is to be paid to a special needs trust under Probate Code section 3604, all statutory liens in favor of the state Department of Health Care Services, the state Department of State Hospitals, the state Department of Developmental Services, and any city and county in California must first be satisfied by the following method (specify): Continued on Attachment 8b(3).

9. Further orders of the court concerning blocked accounts

   The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked account under item 8b(1): a. Within 48 hours of receipt of a check or draft described in item 8b(1), the petitioner and the petitioner's attorney, if any, must deposit the check or draft in the name of petitioner in the petitioner's representative capacity in one or more blocked accounts at (specify name, branch, and address of each depository, and the amount of each account): Continued on Attachment 9a.

MC-351 [Rev. January 1, 2021] ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Page 3 of 4 OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-351 CASE NAME: CASE NUMBER:

9. b. The petitioner and the petitioner's attorney, if any, must deliver to each depository at the time of deposit three copies of the Order to Deposit Funds in Blocked Account (form MC-355), which is signed at the same time as this order, and three copies of the Acknowledgment of Receipt of Order and Funds for Deposit in Blocked Account (form MC-356). The petitioner or the petitioner's attorney must file a copy of the receipt with this court within 15 days of the deposit. The sole responsibilities of the petitioner and the petitioner's attorney, if any, are to place the balance in a blocked account or accounts and to file a copy of the receipt on time. c. The balance of the proceeds of the settlement or judgment deposited in a blocked account or accounts under item 8b(1) may be withdrawn only as follows (check (1) or (2)): (1) No withdrawals of principal or interest may be made from the blocked account or accounts without a further written order under this case name and number, signed by a judicial officer, and file-stamped by this court. The money on deposit is not subject to escheat. (2) The blocked account or accounts belong to a minor, who was born on (date): No withdrawals of principal or interest may be made from the blocked account or accounts without a further written order under this case name and number, signed by a judicial officer, and file-stamped by this court, until the minor reaches 18 years of age. When the minor reaches 18 years of age, the depository, without further order of this court, is authorized and directed to pay by check or draft directly to the former minor, on proper demand, all funds, including interest, deposited under this order. The money on deposit is not subject to escheat.

10. Authorization to execute settlement documents

The petitioner is authorized to execute settlement documents as follows (check only one): a. On receipt of the full amount of the settlement sum approved by this order and the deposit of funds, the petitioner is authorized and directed to execute and deliver to the payer (1) a full, complete, and final release and discharge of any and all claims and demands of the claimant by reason of the accident or incident described in the petition and the resultant injuries to the claimant and (2) a properly executed dismissal with prejudice. b. The petitioner is authorized and directed to execute any and all documents reasonably necessary to carry out the terms of the settlement. c. The petitioner is authorized and directed to (specify):

Continued on Attachment 10c.

11. Bond is ordered and fixed in the amount of: $ not required.

12. A copy of this order must be served on the payer immediately.

13. Additional orders

    The court makes the following additional orders (specify):

    Continued on Attachment 13.

Date:

JUDICIAL OFFICER

SIGNATURE FOLLOWS LAST ATTACHMENT

MC-351 [Rev. January 1, 2021] ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Page 4 of 4 OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form

MC-355 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE STREET ADDRESS: 3390 Harbor Boulevard MAILING ADDRESS: 3390 Harbor Boulevard CITY AND ZIP CODE: Costa Mesa 92626 BRANCH NAME: Costa Mesa Justice Complex CASE NAME:

CASE NUMBER:

ORDER TO DEPOSIT FUNDS IN BLOCKED ACCOUNT

1. The petition of (name): , acting as (specify representative capacity): of the person named in item 2, to deposit funds in one or more blocked accounts came on for hearing on (date): at (time): in Dept.: .

THE COURT ORDERS 2. Funds that belong to (name): must be deposited in one or more interest-bearing, federally insured blocked accounts.

3. Each account must be opened in the legal name of the petitioner as parent guardian conservator other (specify relationship): of the person named in 2.

4. The total amount authorized for deposit, including any accrued interest, is: $

5. Withdrawals (check a or b): a. No withdrawal of principal or interest may be made from the blocked account or accounts without a written order under this case name and number signed by a judicial officer and file-stamped by this court. The money on deposit is not subject to escheat. b. The funds in the blocked account or accounts belong to a minor, who was born on (date): . No withdrawal of principal or interest may be made from the blocked account or accounts without a written order under this case name and number signed by a judicial officer and file-stamped by this court until the minor reaches 18 years of age. When the minor reaches 18 years of age, the depository, without further order of this court, is authorized and directed to pay by check or draft directly to the former minor, on proper demand, all funds, including interest, deposited under this order. The money on deposit is not subject to escheat.

6. The petitioner and the petitioner's attorney, if any, must (1) deliver a copy of this order to each depository in which funds are deposited under this order and (2) file with this court an acknowledgment from each depository of receipt of this order and the funds within 15 days of deposit.

Date:

JUDICIAL OFFICER

Form Adopted for Mandatory Use Code of Civil Procedure, § 372; Judicial Council of California ORDER TO DEPOSIT FUNDS IN BLOCKED ACCOUNT Probate Code, §§ 3500, 3600–3613;MC-355 [Rev. January 1, 2021] Cal. Rules of Court, rules 3.1384, 7.953 For your protection and privacy, please press the Clear www.courts.ca.gov This Form button after you have printed the form. Print this form Save this form Clear this form

MC-356 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME:

FIRM NAME:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

TELEPHONE NO.: FAX NO.:

EMAIL ADDRESS:

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE STREET ADDRESS: 3390 Harbor Boulevard MAILING ADDRESS: 3390 Harbor Boulevard CITY AND ZIP CODE: Costa Mesa 92626 BRANCH NAME: Costa Mesa Justice Complex CASE NAME:

CASE NUMBER:

ACKNOWLEDGMENT OF RECEIPT OF ORDER AND FUNDS FOR DEPOSIT IN BLOCKED ACCOUNT

(Attach a copy of Order to Deposit Funds in Blocked Account (form MC-355) to this receipt.)

1. I acknowledge receipt of the Order to Deposit Funds in Blocked Account (form MC-355), a copy of which is attached to this form, and of the funds specified in item 7, below.

2. The account described below, in which funds have been deposited under the court's order, is an interest-bearing, federally insured blocked account.

3. Name and title on account:

4. Name of depository: a. Branch: b. Address:

5. Account number:

6. Date account opened:

7. Amount of initial deposit: $

8. Current balance: $

I certify that the foregoing information is true and correct, that I am authorized to execute this acknowledgment of receipt on behalf of the depository named in 4, and that no withdrawal of principal or interest from this account will be permitted without a signed, file- stamped order under this case name and number from the court named above.

Date:

(TYPE OR PRINT NAME) (AUTHORIZED SIGNATURE)
Title:

Form Adopted for Mandatory Judicial Council of California Use ACKNOWLEDGMENT OF RECEIPT OF ORDER AND ProbateCodeCode,of Civil§§3500,Procedure,3600–3613;§ 372; MC-356 [Rev. January 1, 2021] FUNDS FOR DEPOSIT IN BLOCKED ACCOUNT Cal. Rules of Court, rules 3.1384, 7.953 www.courts.ca.gov For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form

Disability Accommodation MC-410 CONFIDENTIAL Request

Clerk receives and date stamps here.

If you have a disability and need an accommodation while you are at court, you can use this form to make your request. For more information, see form MC-410-INFO . Make this request at least 5 days (when the court is open) before you need the accommodation. Court Name and Address: 1 Your information Superior Court of California, Name: County of Orange Address: 3390 Harbor Boulevard Costa Mesa, CA 92626 Costa Mesa Justice Complex Phone: Email: Case Number (if you know it): 2 How are you involved in the case? Juror Party Witness Lawyer Case Name/Type (if you know it): Other (explain): 3 When and where do you need the accommodation? [date(s), time(s), and court location]

4 What accommodation do you need at the court?

5 Why do you need this accommodation to assist you in court?

More information on this request is attached.

Date:

Type or print name Signature (Optional) If a court employee, caregiver or other person helped fill out this form and is willing to provide more information if needed, provide contact information below: Name: Email: Phone:

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2021, Optional Form MC-410, Page 1 of 2 Cal. Rules of Court, rule 1.100 Disability Accommodation Request

Case Number (if you know it): Name: Court fills out below (Optional) Important! If your case is delayed or dismissed after you make this request and you do not need the accommodation for the date you specified under 3, please contact the court at: Phone: Email:

Your request is GRANTED. The court will provide the accommodation(s) requested.

Your request is DENIED IN WHOLE OR IN PART. The denied portion of your request: Does not meet the requirements of Cal. Rules of Court, rule 1.100 . Creates an undue financial or administrative burden for the court. Changes the basic nature of the court's service, program, or activity. Explain the reasons supporting the box(es) checked above:

Instead, the court will provide the following accommodation(s):

The court will provide the accommodation(s): For the date(s) and time(s) requested Indefinitely On date(s):

More information on this decision is attached.

Date:

Type or print name Signature The court responded in person, by phone, or mail/email on: Note: You may be able to ask for a review of this decision. Cal. Rules of Court, rule 1.100(g) explains how to do this.

Rev. January 1, 2021 MC-410, Page 2 of 2 Disability Accommodation Request

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