(CAPTION)
ORDER OF COURT
AND NOW, this _____day of ________, 20___, at _______.m., upon consideration of the Petition for Approval of Wrongful Death and Survival Settlement, noting the consent of the Pennsylvania Department of Revenue, and the certification filed by counsel, the Court finds that there are no outstanding unpaid creditors of the Estate and that the proposed settlement of the civil survival action is adequate to protect the interests of the estate and beneficiaries, IT IS THEREFORE ORDERED AND DECREED that payment of ____________Dollars ($_________) in settlement of the Survival Action is
APPROVED.
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,
___________________________
Sch. Cnty. Pa. 2206