Daup. Cnty. Pa. 2039A
___________, Parent and Natural Guardian of ___________, a minor, | : | In the Court of Common Pleas Dauphin County, Pennsylvania |
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Plaintiff | : | |
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v. | : | No. |
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_________________, | : | |
Defendant | : |
ORDER
AND NOW THIS _______ day of ________, 20____, upon consideration of the Petition for Approval of Minor's Settlement, 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 above defendant(s).
The settlement amount shall be distributed as follows:
TO: _____________, attorney at law, $_____ for counsel fees;
TO: _____________, attorney at law, $_____ for reimbursement of costs;
TO: _____________, as Parent and Natural Guardian of _________, a minor, $________ to be deposited into a restricted, federally insured account marked "No withdrawals prior to age 18 without prior court approval."
TOTAL AMOUNT OF DISTRIBUTION: $________
Counsel shall provide to the Court, within ten (10) days from the date of this order proof of such deposit.
BY THE COURT:
__________________________
J.
Daup. Cnty. Pa. 2039A