Preview
MC-350
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT
USE ONLY
| Timothy W. Mazzela, Esq. - SBN #166473 E-FILED
Law Office of Timothy W. Mazzela 9/11/2019 6:27 PM
1875 E, Alluvial Avenue, Suite 101, Fresno, California 93720 Superior Court of California
TELEPHONE NO: (559) 297-1118 FAX NO. (Optional: (559)297-1194 County of Fresno
E-MAIL ADDRESS (Optional): By: K. Daves, Deputy
ATTORNEY FOR (Name): Plaintiff, Lilyan Seyler, a minor
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Fresno
srreer aooress; 1130 'O' Street
MAILING ADDRESS:
CITY AND zip coe: Fresno, California 93721
BRANCH NAME: Unlimited Civil - B.F. Sisk Courthouse
CASE NAME: ‘CASE NUMBER:
Seyler vs. Haines 18CECG02569
HEARING DATE:
PETITION TO APPROVE: (] COMPROMISE OF DISPUTED CLAIM
[7] COMPROMISE OF PENDING ACTION AONGH19
[J DISPOSITION OF PROCEEDS OF JUDGMENT pEPT: 504 TIME: 3:30 pm
Lv] Minor [] Person with a Disability
NOTICE TO PETITIONERS:
Except as noted befow, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor,
(2) the compromise of a pending action or proceeding in 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 for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob.
Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or
examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment,
and hospitalization. The court may consider on an expedited basis without a hearing requests for approval of the compromises of
certain claims and actions or the disposition of the proceeds of certain judgments. {f your claim, action, or judgrnent qualifies for
expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule
7,950.5,
4 Petitioner (name); Tabatha Altuzarra
2. Claimant (name): Lilyan Seyler
a. Address: 1926 E. Quincy Avenue, Fresno, California 93720 (559) 936-6554.
b, Date of birth; 08/16/2008 c. Age: 4 d. Sex: Female 9, Minor (—] Person with a disability
3. Relationship Petitioner's relationship to the claimant (check all applicable boxes):
Parent g. [J Other relationship (specify:)
Guardian ad litem
Guardian
Conservator
Disabled adult claimant is a petitioner. (See instructions for items 3e and 3f below.)
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f.
(if you checked item 3e or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate
Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient eapacity and who does not
have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.)
4. Nature of claim The claim of the minor or adult person with a disabllity:
a. C1 Has not been filed in an action ot proceeding. (Complete items 5-23.)
ls the subject ofa pending action or proceeding that will be compromised without a trial on the merits of the claim.
Name of court: Fresno Superior Court
Case no.:1@CECG02569 Trial date: TBD (Complete items 5-23.)
Page 1 of 10
Form Adopted for PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Code of Civii Procedure, § 372 et sea
‘Altomative Mandatory Use bata Code, § 3600 et s
Judielat Counall of California OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal, Rules of Court, rules 3.1384,
MC-350 (Rev. Janvary 1, 2011} 7.404, 7.980, 7.951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY wanw.courts.ca.gov
(Miscellaneous)
MC-350
CASE NAME: (CASE NUMBER:
| Seyler vs, Haines A9CECG02569
4, Nature of claim The claim of the minor or adult person with a disability:
¢. Is the subject ofa pending action or proceeding that has been or will be reduced to a judgment for the claimant against
s [e500]
the defendants named below in the total amount (exclusive of interest and costs) of (specify below):
Defendants (names,
Diana Haines
{[] Additional defendants listed on Attachment 4. [] The judgment
was filed on (date):
{Altach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.)
Incident or accident The incident or accident occurred as follows:
a. Date and time: September 22, 2017
b. Place: at or the south and west north of Quincy Avenue, city of Fresno, county of Fresno, state of California.
c. Persons involved (names): Lilyan Seyler, a minor, by and through her Guardian ad Litem and: defendant, Diana Haines
[1] Continued on Attachment 5.
6 Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe):
On or about September 22, 2017, the defendants, and each of them, negligently, operated, and drove their vehicle turning
onto Quincy Avenue, city of Fresno, county of Fresno, state of California. The plaintiff was riding her bike on Quincy Avenue
and as she entered the roadway, the defendant turned the corner off of Maple Avenue onto Quincy Avenue and struck the
plaintiff on her bike with her motor vehicle. As a direct and proximate result of the subject motor vehicle incident, the plaintiff
sustained personal injuries to right wrist, forearm, bilateral knee pain and left shin pain.
[2 Continued on Attachment 6,
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Claimant, Lilyan Seyler, sustained personal injuries including: right wrist deformity 2+ radial force, tenderness to palpation of the
bilateral knee and lower legs with a 1 cm laceration/puncture wound to the feft lateral lower leg. There was aiso abrasions to the left
forehead/chin, right elbow, right hand, right flank, right knee, left elbow and shoulder with multiple contusions to the bilateral lower
legs/foot. An x-ray of the chest and pelvis were taken and would return negative. X-rays of the right and left knee and left lower leg
were taken and would return negative. X-rays of the right wrist were taken and would reveal a displaced distal radius fracture, intra-
articular. She was placed under general endotracheal anesthesia. The fracture was reduced, placement of the case was
. :
(] Continued on Attachment 7.
Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
At Valley Children's Hospital a physical examination was performed, x-rays of the right and left knee and left iower leg were taken
and would return negative. X-rays of the right wrist were taken and would reveal a displaced distal radius fracture, intra-articular.
She was placed under general endotracheal anesthesia. The fracture was reduced, placement of the case was then administered.
Claimant received follow up medicat treatment at Valley children's Medical Clinic. Claimant healed satisfactory and was released
from medical care, The release from medical care report is attached hereto.
[] _ Continued on Attachment 8.
MC-950 (Rov. January 1, 2041) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 2010
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: ‘CASE NUMBER:
|-Seyler vs. Haines 19CECG02569
Extent of injuries and recovery (An original or a photocopy of all doctors’ reports containing a diagnosis of and prognosis
for the claimant's injuries, and a report of the claimant's present condition, must be altached to this petition as Attachment 9.
Anew report is not necassary so long as a previous report accurately describes the claimant's current condition )
a, [7] The claimant has recovered completely from the effects of the injuries described in item 7, and there are no
permanent injuries.
b, [-_] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
fram which the claimant has not recovered are temporary (desoribe the remaining injuries):
[J Continued on Attachment 9b.
c, [_] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries):
[1 Continued on Attachment 90.
10. [2] Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to 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 fully understands that if the compromise proposed in this
petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further
recovery of compensation from the settling defendants named below even though the claimant's injuries may in
the future appear to be more serious than they are now thought to be.
11 Amount and terms of settlement
By way of settlement, the defendants named below have offered to pay the following sums to the claimant.
a, The total amount offered by all defendants named betow is (specify). sBs00000i
b. The defendants and amounts offered by each are as follows (specify):
lefendants (names) Amounts
Diana Haines 9 55,000.00
$
$
8
$
[__] Defendants and amounts offered continued on Attachment 11
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).
The settlement is to be paid in one lump sum of $55,000.00 conditioned upon approval of this petition. The net settlement
to claimant will be invested into a Single Premium Annuity to be payable to claimant when she reaches the age of majority
according to the terms and conditions set forth in the annuity contract,
[1 continued on Attachment 11
MG-280 (Rev, January 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 3 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
}-Seyler vs. Haines 49CECG02569
42. Settlement payments to others
a. No defendant named in item 11» 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 CI By way of settlement, one or more defendants named in item 11b have also offered to pay money to a person or
persons other than claimant to settle claims arising out of the same incident or accident that resulted in the
claimant's injury.
(1) The total amount offered by all defendants to others (specify): $
(2) Petitioner isnot (__] isa claimant against the recovery of the claimant (other than for
reimbursement for expenses paid by petitioner and listed under item 15).
(if you answered "is," explain in Attachment 12 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 12 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
$
$
$
$
[4 additional plaintiffs or claimants and amounts are listed on Attachment 12.
(8) Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 12.
13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
a. Totals
(4) Total medical expenses: g 15,317.36
(2) Total outstanding medical expenses to be paid from the proceeds: 5 (a7
(3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds: $
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(1) Paid by petitioner in the amount of: sO
(2) Paid by private health insurance or a self-funded plan under:
(a) [1] An Employee Retirement income Security Act (ERISA) insured plan.
(b) [] An ERISA self-funded pian.
(c) ANon-ERISA insured plan.
(d) C2] ANon-ERISA self-funded plan.
(e) Amount paid by plan: $ 4,919.33
() Amount of reimbursement to the plan from proceeds of settlement or judgment:
@® [1 No reimbursement is requested by the plan,
i) Reimbursement is to be made to the plan and:
(A) (] There is a contractual reduction of $ (
(8) There Is a negotiated reduction of $ ( 99.03,
(c) [1] No reduction has been agreed to,
for a total reimbursement to the plan in the amount of: s (Sem
MC-360 (Rev. January 1, 2014] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page
4 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: (CASE NUMBER:
[Seyler vs. Haines 49CECG02569
43. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
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: sf]
(Attach a copy of the final Medicare demand letter or leller agreement as Attachment 13b(3).)
@) Co Paid by Medi-Cal in the amount of $
(a) [_] Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
and institutions Code section 14124,73. A copy of the notice and proof of its delivery {_] is attached.
[1 was filed in this matter on (date).
© Co Notice of this claim or action has not been given to the State Director of Health Care Services
(Explain why notice has not been given in Attachment 13b(4).)
) CI 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 13b(4).)
@ CO Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code
section 14124.76 and:
(i) (7 Is filing a motion seeking a reduction of the lien concurrently with this petition,
(i) [77] Requests that the court reserve jurisdiction over this issue.
The amount of the lien in dispute is: $
(8) [Z] (a) There are one or more statutory or contractual liens of medical service providers for payment of medical
expenses, The total amount claimed under these llens is: $ 19,661.71 In full satisfaction
of their lien claims, the lienhoiders have agreed to accept the total sum of 3
(Provide requested information on each lienholder and certain other medical service providers below.)
(b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a fien for ail
or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction 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 A) Provider (name): American Ambulance
(8) Address: 2911 Tulare St, Fresno, CA 93721
(c) jount charged: $ 1,150.17
(D) Amount paid (whether or not by insurance): $ (1,150.17
{E) Negotiated reduction, if any: $¢ 0000
00.00
(FY Amount to be paid from proceeds of settlement orjudgment:$ [61563
Cee) =
(i) A) Provider (name): Valley Children's Hospital
8 Address: 9300 Vailey Children's Pl, Madera, CA 93636
(c) Amount charged: $ 19,661.71
(D) Amount paid (whether or not by insurance): 00.00 $
(E) Negotiated reduction, if any: $(_780465
(F) Amount to be paid from proceeds of settlement or judgment $ [11,797.06
Tere |
Continued on Attachment 13b(5). (Provide information about additional providers in the above format,
including providers paid or to be paid by petitioner for which reimbursement is requested in item 13b(1)
above. You may use form MC-350(A-13b(5)) for this purpose.)
MC-960 [Rev, January 4, 2081} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago
6 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: ‘CASE NUMBER:
}-Seyler vs. Haines 19CECG02569
44. The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settleme! nt or judgment
a. Total amount of attorney's fees for which court approval is requested: $
(if fees are requested, attach as Attachment 14a, 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 18a(2) on page 7 and
allach a copy of any written attorney fee agreement as Altachment 18a.)
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) Arnounts
Court Filing Fees § 438.75
[-.] Continued on Attachment 14b. Total: $438.75
15. Reimbursement of expenses paid by petitioner
a. [_] Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested.
Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which
reimbursement Is requested.
(1) Medicat expenses listed in item 13: g 15,317.36
Attorney's fees included in the total fee amount shown in item 44a: $ 13,640.34
2)
(3) Other expenses included in the total shown in item 14b: $ 438,75
Total: s feos
{Attach proofs of the expenses incurred and payments made or obligations to pay incurred, e.g., bills or invoices,
cancatled checks, credit card statements, explanations of benefits from insurers, etc.)
16, 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: (2550568
47. Summary
a, Gross amount of proceeds of settlement or judgment for claimant: 55,000.00
b. Medical expenses to be paid from proceeds of settlement
or judgment: $ 15,317.36
Attorney's fees to be paid from proceeds of settlement or
judgment: $ 13,640.31
Expenses (other than medical) to be paid fron proceeds
438.75
of settlement or judgment: $
Total of fees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c), and (d)):
$ (29,398.42 )
3 (e086
Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (a) from (a)):
NMC-350 fRev. January 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 6 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
|
MC-350
CASE NAME: ‘CASE NUMBER:
‘Seyler vs. Haines 19CECG02569
Information about attorney representing or assisting petitioner
a. (1) (77) 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. (Go to item 19.)
(2) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim
asserted, Petitioner and the attomey [__] do not do have an agreement for services provided in
connection with the claim giving rise to this petition. (/f you answered “do,” atlach a copy of the agraement as
Attachment 18a, and complete items 18b.-18f.)
The attorney who has represented or assisted petitioner is (name): Timothy W. Mazzela
(1) State Bar number: 166473
(2) Law firm: Law Office of Timothy W. Mazzeia
(3) Address:
1875 East Alluvial Avenue, Suite 101, Fresno, California 93720
(4) Telephone number: (659) 297-1118
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. (lf you answered "has," identify the person
who paid the fees or other compensation, the amounts paid, and the dates of payment):
From whom (names) Armounts Dates
[1 Continued on Attachment 180.
The attorney [¥] didnot [_] did become coneemed 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 18d.)
The attorney [7] isnot [__] 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 18e.}
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 date:
{] Continued on Attachment 18f.
MC-350 (Rev, January 4, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page
7 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
| Seyler vs. Halnes 49CECG02569
19, Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
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.:
“Cos of the proceeds in money or other property will be paid or delivered to
the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money
or other property is specified in Attachment 19a(1).
@ CI 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 19a(1) with one or more financiat institutions in this state or with a trust
company, subject to withdrawal only as authorized by the court. The money or other property and the name,
branch, and address of each financial institution or trust company are specified in Attachment 19a(2).
6) C4 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):
@) 1s will be deposited in insured accounts in one or more financial
institutions in this state from which no withdrawals can be made without a court order.
The name, branch, and address of each depository are specified in Attachment 19a(3).
®) [a $ will be invested in a single-premium deferred annuity subject to
withdrawal only on order of the court. The terms and conditions of the annuity are specified in
Attachment 19a(3).
© [4 $ will 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 19a(3).
@ C7 will be transferred to the trustee of a trust that is either created by or
approved of in the order approving the settlement or the judgment given or to be given for the
minor. This trust is revocable when the minor attains the age of 18 years 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 19a(3).
(C_] A copy of the (proposed) judgment is attached as Attachment 4c.
@ Co $ will be transferred to the trustee of a special needs trust under
Probate Code sections 3602(d) and 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 19a(3).
MC-250 (Rev, January 1, 2014] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page
8 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
{Miscellaneous}
MC-350
CASE NAME: CASE NUMBER:
}~Seyler vs. Haines 19CECG02569
19, Disposition of balance of proceeds of settlement or judgment (cont.)
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
b, [¥] There Is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability.
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
(check all that apply):
(4) [[_] A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability
willbe appointed. $ of money and other property will be paid or delivered
to the person so appointed. The money or other property are specified in Attachment 19b(1).
2 $ of money will be deposited in insured accounts in one or more financial
institutions in this state, subject to withdrawal only upon the authorization of the court. The name,
branch, and address of each depository are specified in Attachment 19b(2).
8) $ 25,603.68 of money will be invested in a single-premium deferred annuity, subject to
withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified
in Attachment 190(3).
4 Co $ will be paid or transferred to the trustee of a special needs trust under
Probate Code sections 3604 and 3611(c) 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 19b(4).
@ $ will be paid or delivered to a parent of the minor, upon the terms and under the
conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the
parent and the money or other property to be delivered are specified in Attachment 19b(5). (Value of minor's
entire estate, including the money or property fo be delivered, must not exceed $5,000.)
6) CI $ will 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 19b(6).
@ [J $ will be transferred to the trustee of a trust that is either created by or
approved of in the order approving the settlement or the judgment given or to be given for the minor. This
trust is revocable when the minor attains the age of 18 years 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 19b(7).
[1] A copy of the (proposed) judgment is attached as Attachment 4c.
8) [] $ of money will be held on such conditions as the court in its discretion determines
is in the best interest of the minor or the adult person with a disability. The propased conditions are specified
on Attachment 190(8). (Value must not exceed $20,000.)
@ C) $ of property other than money will be held on such conditions as the court in its
discretion determines Is in the best interest of the minor or the adult person with a disability, The proposed
conditions and the property are specified in Attachment 19b(9).
(10) [J $ will be deposited with the county treasurer of the County of (name):
The deposit is authorized under and subject to the conditions specified in Probate Cade section 361 1(h).
(1) $ will be paid or transferred to the adult person with a disability. The money or other
property is specified in Attachment 19b(11).
[1 Continued on Attachment 19.
MC-380 [Rev. January t, 201 1] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 8 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
[Seyler vs. Haines 19CECG02569
20, [1] Statutory
liens for special needs trust
Petitioner requests a court order for payment of funds to a special needs trust (explain how statutory liens under Probate
Code section 3604, if any, will be satisfied):
[1 Continued on Attachment 20.
21, [(_] Additional orders
Petitioner requests the following additional orders (specify and explain):
(J Continued on Attachment 21.
22, Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to
the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise
settlement or proposed disposition and make such other and further orders as may be just and reasonable.
23. Number of pages attached:
Pate ut) 14
Timothy W. Mazzela, Esq.
(TYPE OR PRINT NAME OF ATTORNEY)
> Lath, (SIGNATURE
bi Meg OF ATTORNEY)
{ declare under penaity of perjury under the laws of the State of California that the foregoing is true and correct.
Date: a/ U1 | /4
Tabatha Altuzarra
(TYPE OR PRINT NAME OF PETITIONER)
WVokala (SIGNATURE
(Baya OF PETTIO(fR)
‘MC-350 {Rev. January 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 10 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
PROOF OF SERVICE
STATE OF CALIFORNIA, COUNTY OF FRESNO
I declare as follows:
I am a
Preview
MC-350 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY | Timothy W. Mazzela, Esq. - SBN #166473 E-FILED Law Office of Timothy W. Mazzela 9/11/2019 6:27 PM 1875 E, Alluvial Avenue, Suite 101, Fresno, California 93720 Superior Court of California TELEPHONE NO: (559) 297-1118 FAX NO. (Optional: (559)297-1194 County of Fresno E-MAIL ADDRESS (Optional): By: K. Daves, Deputy ATTORNEY FOR (Name): Plaintiff, Lilyan Seyler, a minor SUPERIOR COURT OF CALIFORNIA, COUNTY OF Fresno srreer aooress; 1130 'O' Street MAILING ADDRESS: CITY AND zip coe: Fresno, California 93721 BRANCH NAME: Unlimited Civil - B.F. Sisk Courthouse CASE NAME: ‘CASE NUMBER: Seyler vs. Haines 18CECG02569 HEARING DATE: PETITION TO APPROVE: (] COMPROMISE OF DISPUTED CLAIM [7] COMPROMISE OF PENDING ACTION AONGH19 [J DISPOSITION OF PROCEEDS OF JUDGMENT pEPT: 504 TIME: 3:30 pm Lv] Minor [] Person with a Disability NOTICE TO PETITIONERS: Except as noted befow, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor, (2) the compromise of a pending action or proceeding in 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 for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court may consider on an expedited basis without a hearing requests for approval of the compromises of certain claims and actions or the disposition of the proceeds of certain judgments. {f your claim, action, or judgrnent qualifies for expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule 7,950.5, 4 Petitioner (name); Tabatha Altuzarra 2. Claimant (name): Lilyan Seyler a. Address: 1926 E. Quincy Avenue, Fresno, California 93720 (559) 936-6554. b, Date of birth; 08/16/2008 c. Age: 4 d. Sex: Female 9, Minor (—] Person with a disability 3. Relationship Petitioner's relationship to the claimant (check all applicable boxes): Parent g. [J Other relationship (specify:) Guardian ad litem Guardian Conservator Disabled adult claimant is a petitioner. (See instructions for items 3e and 3f below.) Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f. (if you checked item 3e or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient eapacity and who does not have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.) 4. Nature of claim The claim of the minor or adult person with a disabllity: a. C1 Has not been filed in an action ot proceeding. (Complete items 5-23.) ls the subject ofa pending action or proceeding that will be compromised without a trial on the merits of the claim. Name of court: Fresno Superior Court Case no.:1@CECG02569 Trial date: TBD (Complete items 5-23.) Page 1 of 10 Form Adopted for PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Code of Civii Procedure, § 372 et sea ‘Altomative Mandatory Use bata Code, § 3600 et s Judielat Counall of California OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal, Rules of Court, rules 3.1384, MC-350 (Rev. Janvary 1, 2011} 7.404, 7.980, 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY wanw.courts.ca.gov (Miscellaneous) MC-350 CASE NAME: (CASE NUMBER: | Seyler vs, Haines A9CECG02569 4, Nature of claim The claim of the minor or adult person with a disability: ¢. Is the subject ofa pending action or proceeding that has been or will be reduced to a judgment for the claimant against s [e500] the defendants named below in the total amount (exclusive of interest and costs) of (specify below): Defendants (names, Diana Haines {[] Additional defendants listed on Attachment 4. [] The judgment was filed on (date): {Altach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.) Incident or accident The incident or accident occurred as follows: a. Date and time: September 22, 2017 b. Place: at or the south and west north of Quincy Avenue, city of Fresno, county of Fresno, state of California. c. Persons involved (names): Lilyan Seyler, a minor, by and through her Guardian ad Litem and: defendant, Diana Haines [1] Continued on Attachment 5. 6 Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe): On or about September 22, 2017, the defendants, and each of them, negligently, operated, and drove their vehicle turning onto Quincy Avenue, city of Fresno, county of Fresno, state of California. The plaintiff was riding her bike on Quincy Avenue and as she entered the roadway, the defendant turned the corner off of Maple Avenue onto Quincy Avenue and struck the plaintiff on her bike with her motor vehicle. As a direct and proximate result of the subject motor vehicle incident, the plaintiff sustained personal injuries to right wrist, forearm, bilateral knee pain and left shin pain. [2 Continued on Attachment 6, Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Claimant, Lilyan Seyler, sustained personal injuries including: right wrist deformity 2+ radial force, tenderness to palpation of the bilateral knee and lower legs with a 1 cm laceration/puncture wound to the feft lateral lower leg. There was aiso abrasions to the left forehead/chin, right elbow, right hand, right flank, right knee, left elbow and shoulder with multiple contusions to the bilateral lower legs/foot. An x-ray of the chest and pelvis were taken and would return negative. X-rays of the right and left knee and left lower leg were taken and would return negative. X-rays of the right wrist were taken and would reveal a displaced distal radius fracture, intra- articular. She was placed under general endotracheal anesthesia. The fracture was reduced, placement of the case was . : (] Continued on Attachment 7. Treatment The claimant received the following care and treatment for the injuries described in item 7 (describe): At Valley Children's Hospital a physical examination was performed, x-rays of the right and left knee and left iower leg were taken and would return negative. X-rays of the right wrist were taken and would reveal a displaced distal radius fracture, intra-articular. She was placed under general endotracheal anesthesia. The fracture was reduced, placement of the case was then administered. Claimant received follow up medicat treatment at Valley children's Medical Clinic. Claimant healed satisfactory and was released from medical care, The release from medical care report is attached hereto. [] _ Continued on Attachment 8. MC-950 (Rov. January 1, 2041) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 2010 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: ‘CASE NUMBER: |-Seyler vs. Haines 19CECG02569 Extent of injuries and recovery (An original or a photocopy of all doctors’ reports containing a diagnosis of and prognosis for the claimant's injuries, and a report of the claimant's present condition, must be altached to this petition as Attachment 9. Anew report is not necassary so long as a previous report accurately describes the claimant's current condition ) a, [7] The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent injuries. b, [-_] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries fram which the claimant has not recovered are temporary (desoribe the remaining injuries): [J Continued on Attachment 9b. c, [_] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): [1 Continued on Attachment 90. 10. [2] Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to 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 fully understands that if the compromise proposed in this petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further recovery of compensation from the settling defendants named below even though the claimant's injuries may in the future appear to be more serious than they are now thought to be. 11 Amount and terms of settlement By way of settlement, the defendants named below have offered to pay the following sums to the claimant. a, The total amount offered by all defendants named betow is (specify). sBs00000i b. The defendants and amounts offered by each are as follows (specify): lefendants (names) Amounts Diana Haines 9 55,000.00 $ $ 8 $ [__] Defendants and amounts offered continued on Attachment 11 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). The settlement is to be paid in one lump sum of $55,000.00 conditioned upon approval of this petition. The net settlement to claimant will be invested into a Single Premium Annuity to be payable to claimant when she reaches the age of majority according to the terms and conditions set forth in the annuity contract, [1 continued on Attachment 11 MG-280 (Rev, January 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 3 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: }-Seyler vs. Haines 49CECG02569 42. Settlement payments to others a. No defendant named in item 11» 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 CI By way of settlement, one or more defendants named in item 11b have also offered to pay money to a person or persons other than claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. (1) The total amount offered by all defendants to others (specify): $ (2) Petitioner isnot (__] isa claimant against the recovery of the claimant (other than for reimbursement for expenses paid by petitioner and listed under item 15). (if you answered "is," explain in Attachment 12 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 12 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 $ $ $ $ [4 additional plaintiffs or claimants and amounts are listed on Attachment 12. (8) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 12. 13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment a. Totals (4) Total medical expenses: g 15,317.36 (2) Total outstanding medical expenses to be paid from the proceeds: 5 (a7 (3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds: $ b. Medical expenses were paid and are to be reimbursed from proceeds as follows: (1) Paid by petitioner in the amount of: sO (2) Paid by private health insurance or a self-funded plan under: (a) [1] An Employee Retirement income Security Act (ERISA) insured plan. (b) [] An ERISA self-funded pian. (c) ANon-ERISA insured plan. (d) C2] ANon-ERISA self-funded plan. (e) Amount paid by plan: $ 4,919.33 () Amount of reimbursement to the plan from proceeds of settlement or judgment: @® [1 No reimbursement is requested by the plan, i) Reimbursement is to be made to the plan and: (A) (] There is a contractual reduction of $ ( (8) There Is a negotiated reduction of $ ( 99.03, (c) [1] No reduction has been agreed to, for a total reimbursement to the plan in the amount of: s (Sem MC-360 (Rev. January 1, 2014] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 4 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: (CASE NUMBER: [Seyler vs. Haines 49CECG02569 43. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment b. Medical expenses were paid and are to be reimbursed from proceeds as follows: 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: sf] (Attach a copy of the final Medicare demand letter or leller agreement as Attachment 13b(3).) @) Co Paid by Medi-Cal in the amount of $ (a) [_] Notice of this claim or action has been given to the State Director of Health Care Services under Welfare and institutions Code section 14124,73. A copy of the notice and proof of its delivery {_] is attached. [1 was filed in this matter on (date). © Co Notice of this claim or action has not been given to the State Director of Health Care Services (Explain why notice has not been given in Attachment 13b(4).) ) CI 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 13b(4).) @ CO Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and: (i) (7 Is filing a motion seeking a reduction of the lien concurrently with this petition, (i) [77] Requests that the court reserve jurisdiction over this issue. The amount of the lien in dispute is: $ (8) [Z] (a) There are one or more statutory or contractual liens of medical service providers for payment of medical expenses, The total amount claimed under these llens is: $ 19,661.71 In full satisfaction of their lien claims, the lienhoiders have agreed to accept the total sum of 3 (Provide requested information on each lienholder and certain other medical service providers below.) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a fien for ail or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reduction 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 A) Provider (name): American Ambulance (8) Address: 2911 Tulare St, Fresno, CA 93721 (c) jount charged: $ 1,150.17 (D) Amount paid (whether or not by insurance): $ (1,150.17 {E) Negotiated reduction, if any: $¢ 0000 00.00 (FY Amount to be paid from proceeds of settlement orjudgment:$ [61563 Cee) = (i) A) Provider (name): Valley Children's Hospital 8 Address: 9300 Vailey Children's Pl, Madera, CA 93636 (c) Amount charged: $ 19,661.71 (D) Amount paid (whether or not by insurance): 00.00 $ (E) Negotiated reduction, if any: $(_780465 (F) Amount to be paid from proceeds of settlement or judgment $ [11,797.06 Tere | Continued on Attachment 13b(5). (Provide information about additional providers in the above format, including providers paid or to be paid by petitioner for which reimbursement is requested in item 13b(1) above. You may use form MC-350(A-13b(5)) for this purpose.) MC-960 [Rev, January 4, 2081} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago 6 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: ‘CASE NUMBER: }-Seyler vs. Haines 19CECG02569 44. The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settleme! nt or judgment a. Total amount of attorney's fees for which court approval is requested: $ (if fees are requested, attach as Attachment 14a, 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 18a(2) on page 7 and allach a copy of any written attorney fee agreement as Altachment 18a.) 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) Arnounts Court Filing Fees § 438.75 [-.] Continued on Attachment 14b. Total: $438.75 15. Reimbursement of expenses paid by petitioner a. [_] Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested. Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which reimbursement Is requested. (1) Medicat expenses listed in item 13: g 15,317.36 Attorney's fees included in the total fee amount shown in item 44a: $ 13,640.34 2) (3) Other expenses included in the total shown in item 14b: $ 438,75 Total: s feos {Attach proofs of the expenses incurred and payments made or obligations to pay incurred, e.g., bills or invoices, cancatled checks, credit card statements, explanations of benefits from insurers, etc.) 16, 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: (2550568 47. Summary a, Gross amount of proceeds of settlement or judgment for claimant: 55,000.00 b. Medical expenses to be paid from proceeds of settlement or judgment: $ 15,317.36 Attorney's fees to be paid from proceeds of settlement or judgment: $ 13,640.31 Expenses (other than medical) to be paid fron proceeds 438.75 of settlement or judgment: $ Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): $ (29,398.42 ) 3 (e086 Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (a) from (a)): NMC-350 fRev. January 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 6 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) | MC-350 CASE NAME: ‘CASE NUMBER: ‘Seyler vs. Haines 19CECG02569 Information about attorney representing or assisting petitioner a. (1) (77) 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. (Go to item 19.) (2) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim asserted, Petitioner and the attomey [__] do not do have an agreement for services provided in connection with the claim giving rise to this petition. (/f you answered “do,” atlach a copy of the agraement as Attachment 18a, and complete items 18b.-18f.) The attorney who has represented or assisted petitioner is (name): Timothy W. Mazzela (1) State Bar number: 166473 (2) Law firm: Law Office of Timothy W. Mazzeia (3) Address: 1875 East Alluvial Avenue, Suite 101, Fresno, California 93720 (4) Telephone number: (659) 297-1118 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. (lf you answered "has," identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment): From whom (names) Armounts Dates [1 Continued on Attachment 180. The attorney [¥] didnot [_] did become coneemed 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 18d.) The attorney [7] isnot [__] 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 18e.} 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 date: {] Continued on Attachment 18f. MC-350 (Rev, January 4, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 7 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: | Seyler vs. Halnes 49CECG02569 19, Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows: 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.: “Cos of the proceeds in money or other property will be paid or delivered to the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is specified in Attachment 19a(1). @ CI 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 19a(1) with one or more financiat institutions in this state or with a trust company, subject to withdrawal only as authorized by the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 19a(2). 6) C4 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): @) 1s will be deposited in insured accounts in one or more financial institutions in this state from which no withdrawals can be made without a court order. The name, branch, and address of each depository are specified in Attachment 19a(3). ®) [a $ will be invested in a single-premium deferred annuity subject to withdrawal only on order of the court. The terms and conditions of the annuity are specified in Attachment 19a(3). © [4 $ will 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 19a(3). @ C7 will be transferred to the trustee of a trust that is either created by or approved of in the order approving the settlement or the judgment given or to be given for the minor. This trust is revocable when the minor attains the age of 18 years 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 19a(3). (C_] A copy of the (proposed) judgment is attached as Attachment 4c. @ Co $ will be transferred to the trustee of a special needs trust under Probate Code sections 3602(d) and 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 19a(3). MC-250 (Rev, January 1, 2014] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 8 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY {Miscellaneous} MC-350 CASE NAME: CASE NUMBER: }~Seyler vs. Haines 19CECG02569 19, Disposition of balance of proceeds of settlement or judgment (cont.) Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows: b, [¥] There Is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability. Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check all that apply): (4) [[_] A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability willbe appointed. $ of money and other property will be paid or delivered to the person so appointed. The money or other property are specified in Attachment 19b(1). 2 $ of money will be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only upon the authorization of the court. The name, branch, and address of each depository are specified in Attachment 19b(2). 8) $ 25,603.68 of money will be invested in a single-premium deferred annuity, subject to withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified in Attachment 190(3). 4 Co $ will be paid or transferred to the trustee of a special needs trust under Probate Code sections 3604 and 3611(c) 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 19b(4). @ $ will be paid or delivered to a parent of the minor, upon the terms and under the conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the parent and the money or other property to be delivered are specified in Attachment 19b(5). (Value of minor's entire estate, including the money or property fo be delivered, must not exceed $5,000.) 6) CI $ will 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 19b(6). @ [J $ will be transferred to the trustee of a trust that is either created by or approved of in the order approving the settlement or the judgment given or to be given for the minor. This trust is revocable when the minor attains the age of 18 years 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 19b(7). [1] A copy of the (proposed) judgment is attached as Attachment 4c. 8) [] $ of money will be held on such conditions as the court in its discretion determines is in the best interest of the minor or the adult person with a disability. The propased conditions are specified on Attachment 190(8). (Value must not exceed $20,000.) @ C) $ of property other than money will be held on such conditions as the court in its discretion determines Is in the best interest of the minor or the adult person with a disability, The proposed conditions and the property are specified in Attachment 19b(9). (10) [J $ will be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specified in Probate Cade section 361 1(h). (1) $ will be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 19b(11). [1 Continued on Attachment 19. MC-380 [Rev. January t, 201 1] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 8 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: [Seyler vs. Haines 19CECG02569 20, [1] Statutory liens for special needs trust Petitioner requests a court order for payment of funds to a special needs trust (explain how statutory liens under Probate Code section 3604, if any, will be satisfied): [1 Continued on Attachment 20. 21, [(_] Additional orders Petitioner requests the following additional orders (specify and explain): (J Continued on Attachment 21. 22, Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise settlement or proposed disposition and make such other and further orders as may be just and reasonable. 23. Number of pages attached: Pate ut) 14 Timothy W. Mazzela, Esq. (TYPE OR PRINT NAME OF ATTORNEY) > Lath, (SIGNATURE bi Meg OF ATTORNEY) { declare under penaity of perjury under the laws of the State of California that the foregoing is true and correct. Date: a/ U1 | /4 Tabatha Altuzarra (TYPE OR PRINT NAME OF PETITIONER) WVokala (SIGNATURE (Baya OF PETTIO(fR) ‘MC-350 {Rev. January 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 10 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) PROOF OF SERVICE STATE OF CALIFORNIA, COUNTY OF FRESNO I declare as follows: I am a