Preview
MC-350
AYTORNEY OR PARTY WITHOUT ATTORNEY James JohnsonISBN:242241
(Name, Slate Baruumbcr, 9nd address):
FOR counrysgomy
Johnson Attorneys Group
4440 Von Karman Avenue, Sulle100
Newport Beach. CA 92660
E-FILED
TELEWONE No: (94S)566»83DO
9/12/2018 11:23 AM
FAX N0. (949)558-8306
(aprionaa-
Aooness (apumao: albert@}aglegalcom
E-MAIL FRESNO COUNTY SUPERIOR COURT
“HORNE" FORWamefi Sarah Casas. Petitioner By: J. Nelson, Deputy
SUPERIOR COURT 0F CALIFORNIA, COUNTY 0F FY9910
"O” Stree‘
STREET ADDRESS: 1130
1130 "O" Street
MAILING ADDRESS:
crrvAND CODE: Fresno,
ZIP 93724
BRANCH NAME- B.F. Slsk Courthouse
CASE NAME: CASE NUMBER;
JnRe Danie! Mendez, Jr. 18CECG03416
PETITION To APPROVE: COMPROMISE 0F DISPUTED CLAIM “WNW“:
{j COMPROMISE 0F PENDING ACTION
E3 DISPOSITION 0F PROCEEDS 0F JUDGMENT
m Minor m Person With a Disability
DEPT; TIME?
NOTICE TO PETITiONERS:
Except as noted beiow, you must usethisformlo request court
approval of (1) the compromise of a disputed claim of a minor,
compromise
(2) the ofa pending action or proceedingInwhich a mlnor or a person with a dlsablllty (Including a conservatee) is a
me
party; or (3) the disposition of
proceeds of a judgment for a minor or person with a disabllily. (See Code Clv. Proa, § 372: Prob.
Code. § 3600 e2 seq.) You and the m’inor or disabled person must attend the hearing on this petition unless the court for good cause
dlspenses wlth a personal appearance. The court may require the presence and testimony of witnesses. including the attending or
examining physiclan, and o!her evidence reiatlng to the mems of the claim and lhe nature and extent of the Injury. care, treatment.
and hospitatizatlon. The court may consider on an expedited basis without a hearing requests for approval of the compromises of
ma disposmon
cefiain claims and actions or proceeds
of the )udgmenls.
of certain your cialm. action. arjudgment quailfies
If for
expedlted consideration and you want to requestyou must use {orm MC-350EX
It, foryour request. See Cal. Rules of Court.
rule
7.9505.
1, Fetltloner (name): SarahCasas
2' malmam (name); Daniel Mendez. Jr,
a. Address: 1:323 W. Cornell Avehue. Fresno.CA 93705
bv Date of 5‘13‘2001
blrth: c. Agezfi d. Sex: M5” e‘ Minor E Person with adisability
3.
a. D
Relanonship
Parent g.
me
Petitioner's relationship tocialmant (checkallapplicable boxes):
315W (bah Pafems
Other relationship (specify) 3V9 deceased)
b‘
cV a
a
Guardian ad
Guardian
mem
d.
e.
L
D
E
Conservator
Dlsabled adult claimant
Isa petmoner. {See lnslrucllons forilems 39 and 3f below.)
Disabled adult claimant‘s express consent to the
relief requested ln this petition ls provided on Attachment
3f.
(ifyou checked item 3e or3f, on Attachmen! 3e or 3f showing ma! (he claimant has capacity under Probate
state facts
Code section 8 I 2 to pelirion or consent to a perih'on.
Only an adult claimant who has sufficient capac/ty and who does no!
have a conservator of the estate may peiifion or consent Io a petition. See Probate Code section 3613.)
4. Nature of claim The claim of the minor or aduit person With a dlsabilizy:
a.
b, E Has
Is
notbeen flied inan action or proceeding (Complete irems 5—23.)
the subject of a pending action or proceedlng tha1
Name of Court
willbe compromised wfihout a on the merits of the claim.
trial
Case no.1 Trial date: (Complete Items 5-23.)
Panet0t i0
Alleggflmgfifle‘glisa PETITION T0 APPROVE COMPROMISE OF DISPUTED CLAIM °°“°'§',:'L;’§°§:§¢i°§§3§;§
2:3:
JudchaIcDunu'lotCaMnmm
M0450 (Rev, Janvaly 1.2m ll
0R PENDING ACTlON 0R DESPOSITION 0F PROCEEDS 0F cmfimesotmmrummage.
JUDGMENT FOR MINOR 0R PERSON WtTH A DISABILITY 3213332133;
(Miscellaneous)
MC-350
CASE. NAME: CASE NUMBER:
_ln Re Daniel Mendez, Jr.
4. Nature of claim The claim of the minor or adult person with a disabiiity:
c. E3 Isthe subject of a pending action or proceeding that has been or
be reduced
wili to a iudgmenl for the cialmant against
the defendantsnamed below In amount
the total (exciusiveo'f
Defendants
interest
names
s E:::1
and costs) of (specify below}:
[:3 Additional defendan‘s listed on Attachment 4.a The Judgment was filed on (date):
copy or the (proposed) judgment as Arlachmenl 4c and complete Items 13—23.)
(Attach a
5. Incident or accident The incident or accident occurred as follows:
a_ Date and 13mg; December 9.2017; approximately 2:45 a.m.
b. place; Kings Canyon Road and Temperance Avenue. Fresno County. California
c. persons mvowed (names); Daniel Mendez. Sn. Ramona Mendez (Claimant's parents), and Defendani Mlchae! Merrllt-
Huichins (aka Michael MerrlflIll)
E3 Contlnued on Attachment 5.
6. Nature of incldent or accident
The and circumstances
facts. events. of the Incident or accident are (describe):
Danlel and Ramona Mendez, when
Claimant's parents, were delivering newspapers was raar-ended by a
their vehicle
vehide driven by Michael MerrRt-Huichins. Mr. and Mrs. Mendez sustained Mr. Merrltt~Hutchlns
fatal Injuries. iscurrently In
the Fresno County Jan charged with gross vehicular manslaughter while Intoxicated as a result of the coltlsion.
The vehicle
was
Mr. Merritt-Hutchins "ma
driving at the was owned by
of the collision and Michael
his grandparents. Elbra Merritt
Merritt.
[j Continued on Attachment 6.
7. E3 Injuries .
The ronowlng were suslained by
injuries the claimant as a result of the Incident or accldent (describe):
a Continued on Attachment
a
7.
8. Treatment ‘
The claimant receivedthe following care and treatment for the Injuries described
InItem 7 (describe):
D Continued on Attachment 8,
hwvlnevldawaw n20": PETITION To APPROVE COMPROMISE 0F DISPUTED CLAIM Paoemo
0R PENDING ACTION 0R DISPOSITION or PRocssos 0F
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
I M0350
CASE NAME: CASE NUMBER:
4n Re Danlel Mendez. Jr‘
am Exfient of injuries and recovery
forme and a
claimant's Injuries,
or a photocopy of all doctors’ repon‘s containing a diagnosis of and prognosis
(A'n original
report of me claimant's present condition,
must be attachedto (ms petition as Attachment
9.
A new report Is no! necessaly so long as a previous repor? accurately describes (he claimant‘s current condition.)
a. D The claimant has recovered compte-teiy from me effects of the injuries described in item 7. and there are no
permanent Injuries.
b. 1:3 The claimant has not recovered completely from descflbed
the efiects of the injuries InItem 7. and the toliowlng Injuries
from whlch {he claimant has not recovered are temporary (describe the remaining
Injuries):
m Contlnued on Attachment 9b.
C» m The claimant hasno! recovered completely from the effecis of the Injuries described
In
from which the claimant has n01 recovered are permanent (describe (he permanent
Item 7.
Injuries}:
and the following injuries
1o.III
D Continued on Attachment 9c.
Petitloner hasmade a careful and diligent Inquiry
i
and Investigation to ascertain the facts relating to the Incident or
accident m which the claimant was and the nature. extent,
Injured; the responslhillty for the incident or accident;
and seriousness of the clalmant‘s Injuries. Petitioner fulky understands that If the compromlsa proposed in {his
petition is approved by the court and Is consummated, the claimant wiil be (orever barred from seeking any further
recovery of compensatlon from the seflllng 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.
11.11] Amount and terms of settlement
By way of settlement, the yiefendants named beiow have offered to pay the sums
following lo the claimant:
a. The total amount offered by all defendants named belowis (specify): $ 83,333.33
b. The defendants and amounts offered by each are as foilows (specify):
-
Dgfendants (names: Amgunts
Mlchael Merritt-Hutchins (aka Michaei Merritt and Michael
Elbra Merritt;
HI), Merritt
s 50,000.00
+ 33,333.33
$
$
$
E
c.
Defendants and amounts offered continued on Attachment 11.
The terms o! settlement are as foliows
(1f
3
me settlement Is to be paid in Installments,
both me Iota!amount and (he
present value of the settlement must be included):
Defendants have offered $100.000.00 per person bodlly a $200,000.00
total of
Injury policy iimttfor to resolve the
Ramona Mendez. The setfiement amount fordecedem Ramona
wrongful death cialms for Daniel Mendez, Sr. and _
Mendez wifl be shared by her two biological children. Sarah
Casas and Daniel Mendez, ($50,000 each) and the
Jr.
settlementtor decedent Daniel Mendez. 3r.willbe shared by Jasmine Mendez. Sarah
his three blologica! chfldren.
Cases and Daniel Mendez. ($33,333.33 each).
D
Jr.
Continued on Attachment 11.
”0'350l“°V~J=‘""°W1-20“) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAlM Paaeaom
OR'PENDiNG ACTION OR DISPOSITJON OF PROCEEDS OF
JUDGMENT FOR MINOR 0R PERSON WITH A DlSABiUTY
(Mlsceflaneous)
MC-350
CASE NAME: CASE NUMBER:
min Re Danie! Mendez, Jr.
12. E Settlement payments to others
a. [:I No defendant named In money
Item 11b has offered to pay toany person or persons other than the cIaImant
to
settle same
claims arising out of the Incident or accident that resulted In the cialmant's Injury.
b. U] By way of setflement,one or more defendanis named initem 11b have also offered to pay
money to a person or
persons other than claimant same
claims arising out o! the
to settle Incident or accident that resulted in 'the
claimant's injury.
116.66667
(1 J
(2)
The total
Petitioner E
amount ofiered by an defendants
reimbursement
ls
for
not [:3 is
to others (speciry):
expenses paid by petitioner and Hsied under Rem 15).
s
a claimant against the recovery of the claimant (other than
for
"
(h‘you answered "ls, explain in Attachment 12 (ha circumstances and the
effectyour claim has on the
proposed com romise of the claim described In (his petition.)
(3) Petltloner lsnot ls a the
plaintiff insame action wlth the claimant.
"
you answered "is,
(If explain In Attachment 1 2 (he circumstances and the effect your claim and
Itsdisposition
has on the proposed compromise of me claim or action described In this petition.)
(4) would receive money under the proposed settlement.
Petliloner
(5) The settlement payments are tobe apportioned and as foliowx
distributed
Sarah Casas
O he n
iainlifls or cla!
83,333.33
Mg
5
Jasmine Casas
5 33.333.34
$
$
D
C
and amounts are Hated on Attachment
Additiona! plaintiffs or claimants 12.
(6) Reasons for the apportionment of the setuement payments between the cinlmant and each other
or clalmant
plaintiff named above are specified on Attachment 12.
13. The cialmant's medical expenses, Including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
a. Totals
0
::j
(1) Total medicat expenses: ,$
(2) Total outstanding medicalexpenses to be paid from the proceeds: $
(3) Totalout—of‘pocket, co—paymenls. or deducflble payments to be reimbursed from proceeds: $
Medicai expenses were paid and are to be reimbursed from proceeds as follows:
w
b.
(1) [2:] Paid by pemioner in theamount of: $ I I
(2) [:1 Paid by private health Insurance or a seIf-funded pian under:
E3 An Employee Retirement Income
(a)
(b)
(c)
E
D
An ERISA seif—funded plan.
ANon-ERiSAlnsured pfan.
Security Act (ERISA) insured plan.
(d) [j A Non-E'RISA self~funded plan.
G
(e) Amount Paid by plan: $
(f) Amount of reimbursement to the planfrom proceeds of settlement orjudgment:
(I)CZ] No reimbursement lsrequested by the plan.
CI Reimbursement made
(II)
(A) E
E]
There
isto
is
be to the plan and:
a contractual reduction of S
( )
(B)
(C) E There
No
lsa negoflated reduction
reduction has been agreed
reimbursement
{or a total
o-f
to.
$ (
amount
to the plan 1n the
)
of: $
Mcasomemmum mom PETITION T0 APPROVE COMPROMISE OF DISPUTED CLAIM 9699“!“
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY
(Misceilaneous)
MC-350
CASE NAME: CASE NUMBER:
a
-ih Re Daniel Mendez. Jr.
13. The ctaimant's medical expenses, Inciudtng medlcal expenses paid by petitionerand insurers. tobe reimbursed from
pruceeds of settlement or judgment
b. Medical expenses were paid and are to be reimbursed from proceeds as foilows:
(3) C: Paid by Medicare inthe amount of: $
:ess the stalutory feduction
inthe amount of:3 ( )
fora retmbursement
total to Medicare in{heamouni of: 5
(Attach acopy of (he Medicare demand
final letteror letter agre ement as Attachment 13b(3).)
[:3 Paid by Medl-Ca!in theamount of $
(4)
(a) E been given
Notice of thls claim or action has
E
to the State Director of Health CareI'Servlces
under Welfare
(b) a Dand Code
Institutions
was
Notice ofthis
section 14124.73.
on
filed In this matter (date):
A copy of thenoticeand proof of its
delivery l's
attached.
claim or action has not been given to the State Direcior of Health Care Servlces.
(Explainwhy notice has no! been given
In Attachment 13b(4).)
(c) [:3 of
In full satisfaction Hen fights. Medi-Cal has agreed to accept reimbursement
Its
amount
in the of: $
demand letter or letter agreement as Attachment
(Attach a copy of the final Medi-Cal 1313(4).)
(d) CZ] Petitioner
is a reduction oi the Medl-Ca!
entitled to lienunder Welfare and Code
institutions
(i)m
section 14124.76 and:
C:
(ii)
lsflflng a motion seeking a reduction of the Hen concurrently with
Requests that the court reserve judsdl-cfion over this Issue.
this petition.
The amount of the ilen In dispute
is:$
(5) E (a) There are one or more statutory or contractual
expenses. The total
medicai service providers for payment of medical
liens 01
amount cIaimed under these liens
ls: $ .In satisfaction
full
flan claims
of their (he ilenholders have agreed
toaccept thetote!sum of: S l
.
I
{Provide requested Information on each Ilanholder and certain other medical service providers beiow )
(b)The name of each medlea! servlce provider that furnished care and treatment to claimant and (1) has a lien tor alt
or any part of the charges or (2) was paid (or will be paid from the proceeds) by petliloner for which petitioner
requests reimbursement: the amounts charged and paid; the amount of negotiated reduction or charges. Ir any:
and the amount to be paid from the proceeds of the settiement or judgment to each provider are as follows:
(i)(A) Provider (name):
(B) Address:
(C) Amount charged: s
(H)
(D)
(E)
(F)
(A)
Amount paid (whether or not by
Negotiated reduction.
Amount to
Provlder (name).
Ifany.
insurance):
be paid from proceeds
s
of setflement orjudgment: 5 (:3)
( )
(B) Address:
(C) Amount charged: 5
(D) Amount paid (whether or not by insurance): s ( )
(E) Negotiated reduction.
Ifany: s ( )
Amount be paid from proceedsof setiiement orjudgment:$
a (F) to
Contlnued 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 ls requested In Rem 13b(‘l)
above. You may use form MC-350(A-13b(5)) for (his purpose.) I
MC-BSO [Rem Jammy
l,201-1}
PETITION TO APPROVE COMPROMISE 0F DISPUTED CLAiM ”9‘5“”
OR PENDlNG ACT10N OR DISPOSITION 0F PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Mlscel!aneous)
M0350
CASE NAM E: CASE NUMSER:
—|n Re Daniel Mendez.
$—
Jr.
14.The cialmant's attorney's fees and all other expenses (except medical expanses). including expenses
advanced by
claimant's attorney or pald or incurred by petitioner to be reimbursed from proceeds of settiement or
udgment _
a. Totalamount forwhich court approva!
of attorney's fees Isrequested:
fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request, Including
(If
a discussion or applicable factors listed in rule ?.955(b) of the Cal. Rules of Court Respond to Item
18am) on page 7 and
attacha copy of any agreement as Attachment
written attorney fee 1 8a.)
b. The expense (other than medIcal expenses) have bean incurred or paid. are reasonable, resulted
following additional Items or
or accident. and should be paid out of claimant‘s share of the proceeds of the settlement or Judgment:
from the Incident
LLelm Payees (namesl Amounts
3
investigation Thomas Professional Investigation s 300.00
Asset invesllgation and Report USA ExpreSS Legal Support s 275.00
Death Certificates Fresno County Recorder 14.00
s
Notary The UPS Store s 10.00
$
$
$
.
$
$
$
Continued on Attachment 14b. Total: 599.00
s
15. Reimbursement of expenses paid by petitioner
a.
b, a has paid none of the ciaimant‘s expenses listed in items 13 and 14 forwhich reimbursement Is requested.
Petitioner
has paid (or become obligated to pay) the following tota! amounts of the cIaImant's expenses for which
Petitioner
reimbursement ls requested.
(1)
(2)
E
E Medicalexpensesllstedlnitem 13:
Attorney‘s fees Included
in amount shown In Item 14a:
the total fee
$
$
(3) [:3 Other expenses inciuded inthatoialshownlnltem 14b: $
Total: $| I
(Attach proofs of (he
expenses Incurred and payments made or obligations Iopay incurred, or invoices,
9.g., bills
canceled checks, credit card statements, explanations of benefits {rom Insurers,
etc.)
16‘ Net balance of proceeds for thelclaimant
The balance of theproceeds of the proposed settlemenl arjudgment remainingforthe claimant
afterpayment of aH requested feesand expenses is:
$161 382.00
17. Summary
a. Gross amount of proceeds of settlement or iudgmentfor claimant: s 83,333.33
b. Medical expenses to be paid from proceedsof settiement
orjudgment:
S 0
c. be paid from proceeds of settiement or
Attorney's fees to
judgment: $ 20,752.33
d. Expenses (other than medicauto be paid from proceeds
or settlement or judgment: 599.00
3
e.
f.
Total offees and
(add (b), (c),
expenses
and (co):
tobe paid 1mm proceeds of settlement
Baiance of proceeds of settlement or judgment avaliabfe
fees and expenses (subtract(e)from (5)):
for
orjudgmem
claimant after payment of
'
all
3 (3M) _
s 61,982.00
MC'SW‘RW'WW" "”1”
?ETIT!ON TO APPROVE COMPROMSE OF DISPUTED CLAIM "”6”“
OR PENDING ACTSON 0R DISPOSITION OF PROCEEDS OF
JUDGMENT FOR M?NOR OR PERSON WJTH A D!SABILITY
{Mlscellaneous}
CASE NAME:
MC-350
CASE N UMBER?
—ln Re Daniel Mendez, Jr.
18. information about attorney representing or assisting petitioner
a. (1) [:3 has not been represented or assisted by an attorney
Petitioner In preparing thts petition or
inany other way with
respect to the claim asserted. (Go
toItem 19.)
has been represented or assisted by an attorney In preparing thls petition or with respect to the
Preview
MC-350 AYTORNEY OR PARTY WITHOUT ATTORNEY James JohnsonISBN:242241 (Name, Slate Baruumbcr, 9nd address): FOR counrysgomy Johnson Attorneys Group 4440 Von Karman Avenue, Sulle100 Newport Beach. CA 92660 E-FILED TELEWONE No: (94S)566»83DO 9/12/2018 11:23 AM FAX N0. (949)558-8306 (aprionaa- Aooness (apumao: albert@}aglegalcom E-MAIL FRESNO COUNTY SUPERIOR COURT “HORNE" FORWamefi Sarah Casas. Petitioner By: J. Nelson, Deputy SUPERIOR COURT 0F CALIFORNIA, COUNTY 0F FY9910 "O” Stree‘ STREET ADDRESS: 1130 1130 "O" Street MAILING ADDRESS: crrvAND CODE: Fresno, ZIP 93724 BRANCH NAME- B.F. Slsk Courthouse CASE NAME: CASE NUMBER; JnRe Danie! Mendez, Jr. 18CECG03416 PETITION To APPROVE: COMPROMISE 0F DISPUTED CLAIM “WNW“: {j COMPROMISE 0F PENDING ACTION E3 DISPOSITION 0F PROCEEDS 0F JUDGMENT m Minor m Person With a Disability DEPT; TIME? NOTICE TO PETITiONERS: Except as noted beiow, you must usethisformlo request court approval of (1) the compromise of a disputed claim of a minor, compromise (2) the ofa pending action or proceedingInwhich a mlnor or a person with a dlsablllty (Including a conservatee) is a me party; or (3) the disposition of proceeds of a judgment for a minor or person with a disabllily. (See Code Clv. Proa, § 372: Prob. Code. § 3600 e2 seq.) You and the m’inor or disabled person must attend the hearing on this petition unless the court for good cause dlspenses wlth a personal appearance. The court may require the presence and testimony of witnesses. including the attending or examining physiclan, and o!her evidence reiatlng to the mems of the claim and lhe nature and extent of the Injury. care, treatment. and hospitatizatlon. The court may consider on an expedited basis without a hearing requests for approval of the compromises of ma disposmon cefiain claims and actions or proceeds of the )udgmenls. of certain your cialm. action. arjudgment quailfies If for expedlted consideration and you want to requestyou must use {orm MC-350EX It, foryour request. See Cal. Rules of Court. rule 7.9505. 1, Fetltloner (name): SarahCasas 2' malmam (name); Daniel Mendez. Jr, a. Address: 1:323 W. Cornell Avehue. Fresno.CA 93705 bv Date of 5‘13‘2001 blrth: c. Agezfi d. Sex: M5” e‘ Minor E Person with adisability 3. a. D Relanonship Parent g. me Petitioner's relationship tocialmant (checkallapplicable boxes): 315W (bah Pafems Other relationship (specify) 3V9 deceased) b‘ cV a a Guardian ad Guardian mem d. e. L D E Conservator Dlsabled adult claimant Isa petmoner. {See lnslrucllons forilems 39 and 3f below.) Disabled adult claimant‘s express consent to the relief requested ln this petition ls provided on Attachment 3f. (ifyou checked item 3e or3f, on Attachmen! 3e or 3f showing ma! (he claimant has capacity under Probate state facts Code section 8 I 2 to pelirion or consent to a perih'on. Only an adult claimant who has sufficient capac/ty and who does no! have a conservator of the estate may peiifion or consent Io a petition. See Probate Code section 3613.) 4. Nature of claim The claim of the minor or aduit person With a dlsabilizy: a. b, E Has Is notbeen flied inan action or proceeding (Complete irems 5—23.) the subject of a pending action or proceedlng tha1 Name of Court willbe compromised wfihout a on the merits of the claim. trial Case no.1 Trial date: (Complete Items 5-23.) Panet0t i0 Alleggflmgfifle‘glisa PETITION T0 APPROVE COMPROMISE OF DISPUTED CLAIM °°“°'§',:'L;’§°§:§¢i°§§3§;§ 2:3: JudchaIcDunu'lotCaMnmm M0450 (Rev, Janvaly 1.2m ll 0R PENDING ACTlON 0R DESPOSITION 0F PROCEEDS 0F cmfimesotmmrummage. JUDGMENT FOR MINOR 0R PERSON WtTH A DISABILITY 3213332133; (Miscellaneous) MC-350 CASE. NAME: CASE NUMBER: _ln Re Daniel Mendez, Jr. 4. Nature of claim The claim of the minor or adult person with a disabiiity: c. E3 Isthe subject of a pending action or proceeding that has been or be reduced wili to a iudgmenl for the cialmant against the defendantsnamed below In amount the total (exciusiveo'f Defendants interest names s E:::1 and costs) of (specify below}: [:3 Additional defendan‘s listed on Attachment 4.a The Judgment was filed on (date): copy or the (proposed) judgment as Arlachmenl 4c and complete Items 13—23.) (Attach a 5. Incident or accident The incident or accident occurred as follows: a_ Date and 13mg; December 9.2017; approximately 2:45 a.m. b. place; Kings Canyon Road and Temperance Avenue. Fresno County. California c. persons mvowed (names); Daniel Mendez. Sn. Ramona Mendez (Claimant's parents), and Defendani Mlchae! Merrllt- Huichins (aka Michael MerrlflIll) E3 Contlnued on Attachment 5. 6. Nature of incldent or accident The and circumstances facts. events. of the Incident or accident are (describe): Danlel and Ramona Mendez, when Claimant's parents, were delivering newspapers was raar-ended by a their vehicle vehide driven by Michael MerrRt-Huichins. Mr. and Mrs. Mendez sustained Mr. Merrltt~Hutchlns fatal Injuries. iscurrently In the Fresno County Jan charged with gross vehicular manslaughter while Intoxicated as a result of the coltlsion. The vehicle was Mr. Merritt-Hutchins "ma driving at the was owned by of the collision and Michael his grandparents. Elbra Merritt Merritt. [j Continued on Attachment 6. 7. E3 Injuries . The ronowlng were suslained by injuries the claimant as a result of the Incident or accldent (describe): a Continued on Attachment a 7. 8. Treatment ‘ The claimant receivedthe following care and treatment for the Injuries described InItem 7 (describe): D Continued on Attachment 8, hwvlnevldawaw n20": PETITION To APPROVE COMPROMISE 0F DISPUTED CLAIM Paoemo 0R PENDING ACTION 0R DISPOSITION or PRocssos 0F JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) I M0350 CASE NAME: CASE NUMBER: 4n Re Danlel Mendez. Jr‘ am Exfient of injuries and recovery forme and a claimant's Injuries, or a photocopy of all doctors’ repon‘s containing a diagnosis of and prognosis (A'n original report of me claimant's present condition, must be attachedto (ms petition as Attachment 9. A new report Is no! necessaly so long as a previous repor? accurately describes (he claimant‘s current condition.) a. D The claimant has recovered compte-teiy from me effects of the injuries described in item 7. and there are no permanent Injuries. b. 1:3 The claimant has not recovered completely from descflbed the efiects of the injuries InItem 7. and the toliowlng Injuries from whlch {he claimant has not recovered are temporary (describe the remaining Injuries): m Contlnued on Attachment 9b. C» m The claimant hasno! recovered completely from the effecis of the Injuries described In from which the claimant has n01 recovered are permanent (describe (he permanent Item 7. Injuries}: and the following injuries 1o.III D Continued on Attachment 9c. Petitloner hasmade a careful and diligent Inquiry i and Investigation to ascertain the facts relating to the Incident or accident m which the claimant was and the nature. extent, Injured; the responslhillty for the incident or accident; and seriousness of the clalmant‘s Injuries. Petitioner fulky understands that If the compromlsa proposed in {his petition is approved by the court and Is consummated, the claimant wiil be (orever barred from seeking any further recovery of compensatlon from the seflllng 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. 11.11] Amount and terms of settlement By way of settlement, the yiefendants named beiow have offered to pay the sums following lo the claimant: a. The total amount offered by all defendants named belowis (specify): $ 83,333.33 b. The defendants and amounts offered by each are as foilows (specify): - Dgfendants (names: Amgunts Mlchael Merritt-Hutchins (aka Michaei Merritt and Michael Elbra Merritt; HI), Merritt s 50,000.00 + 33,333.33 $ $ $ E c. Defendants and amounts offered continued on Attachment 11. The terms o! settlement are as foliows (1f 3 me settlement Is to be paid in Installments, both me Iota!amount and (he present value of the settlement must be included): Defendants have offered $100.000.00 per person bodlly a $200,000.00 total of Injury policy iimttfor to resolve the Ramona Mendez. The setfiement amount fordecedem Ramona wrongful death cialms for Daniel Mendez, Sr. and _ Mendez wifl be shared by her two biological children. Sarah Casas and Daniel Mendez, ($50,000 each) and the Jr. settlementtor decedent Daniel Mendez. 3r.willbe shared by Jasmine Mendez. Sarah his three blologica! chfldren. Cases and Daniel Mendez. ($33,333.33 each). D Jr. Continued on Attachment 11. ”0'350l“°V~J=‘""°W1-20“) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAlM Paaeaom OR'PENDiNG ACTION OR DISPOSITJON OF PROCEEDS OF JUDGMENT FOR MINOR 0R PERSON WITH A DlSABiUTY (Mlsceflaneous) MC-350 CASE NAME: CASE NUMBER: min Re Danie! Mendez, Jr. 12. E Settlement payments to others a. [:I No defendant named In money Item 11b has offered to pay toany person or persons other than the cIaImant to settle same claims arising out of the Incident or accident that resulted In the cialmant's Injury. b. U] By way of setflement,one or more defendanis named initem 11b have also offered to pay money to a person or persons other than claimant same claims arising out o! the to settle Incident or accident that resulted in 'the claimant's injury. 116.66667 (1 J (2) The total Petitioner E amount ofiered by an defendants reimbursement ls for not [:3 is to others (speciry): expenses paid by petitioner and Hsied under Rem 15). s a claimant against the recovery of the claimant (other than for " (h‘you answered "ls, explain in Attachment 12 (ha circumstances and the effectyour claim has on the proposed com romise of the claim described In (his petition.) (3) Petltloner lsnot ls a the plaintiff insame action wlth the claimant. " you answered "is, (If explain In Attachment 1 2 (he circumstances and the effect your claim and Itsdisposition has on the proposed compromise of me claim or action described In this petition.) (4) would receive money under the proposed settlement. Petliloner (5) The settlement payments are tobe apportioned and as foliowx distributed Sarah Casas O he n iainlifls or cla! 83,333.33 Mg 5 Jasmine Casas 5 33.333.34 $ $ D C and amounts are Hated on Attachment Additiona! plaintiffs or claimants 12. (6) Reasons for the apportionment of the setuement payments between the cinlmant and each other or clalmant plaintiff named above are specified on Attachment 12. 13. The cialmant's medical expenses, Including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment a. Totals 0 ::j (1) Total medicat expenses: ,$ (2) Total outstanding medicalexpenses to be paid from the proceeds: $ (3) Totalout—of‘pocket, co—paymenls. or deducflble payments to be reimbursed from proceeds: $ Medicai expenses were paid and are to be reimbursed from proceeds as follows: w b. (1) [2:] Paid by pemioner in theamount of: $ I I (2) [:1 Paid by private health Insurance or a seIf-funded pian under: E3 An Employee Retirement Income (a) (b) (c) E D An ERISA seif—funded plan. ANon-ERiSAlnsured pfan. Security Act (ERISA) insured plan. (d) [j A Non-E'RISA self~funded plan. G (e) Amount Paid by plan: $ (f) Amount of reimbursement to the planfrom proceeds of settlement orjudgment: (I)CZ] No reimbursement lsrequested by the plan. CI Reimbursement made (II) (A) E E] There isto is be to the plan and: a contractual reduction of S ( ) (B) (C) E There No lsa negoflated reduction reduction has been agreed reimbursement {or a total o-f to. $ ( amount to the plan 1n the ) of: $ Mcasomemmum mom PETITION T0 APPROVE COMPROMISE OF DISPUTED CLAIM 9699“!“ OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY (Misceilaneous) MC-350 CASE NAME: CASE NUMBER: a -ih Re Daniel Mendez. Jr. 13. The ctaimant's medical expenses, Inciudtng medlcal expenses paid by petitionerand insurers. tobe reimbursed from pruceeds of settlement or judgment b. Medical expenses were paid and are to be reimbursed from proceeds as foilows: (3) C: Paid by Medicare inthe amount of: $ :ess the stalutory feduction inthe amount of:3 ( ) fora retmbursement total to Medicare in{heamouni of: 5 (Attach acopy of (he Medicare demand final letteror letter agre ement as Attachment 13b(3).) [:3 Paid by Medl-Ca!in theamount of $ (4) (a) E been given Notice of thls claim or action has E to the State Director of Health CareI'Servlces under Welfare (b) a Dand Code Institutions was Notice ofthis section 14124.73. on filed In this matter (date): A copy of thenoticeand proof of its delivery l's attached. claim or action has not been given to the State Direcior of Health Care Servlces. (Explainwhy notice has no! been given In Attachment 13b(4).) (c) [:3 of In full satisfaction Hen fights. Medi-Cal has agreed to accept reimbursement Its amount in the of: $ demand letter or letter agreement as Attachment (Attach a copy of the final Medi-Cal 1313(4).) (d) CZ] Petitioner is a reduction oi the Medl-Ca! entitled to lienunder Welfare and Code institutions (i)m section 14124.76 and: C: (ii) lsflflng a motion seeking a reduction of the Hen concurrently with Requests that the court reserve judsdl-cfion over this Issue. this petition. The amount of the ilen In dispute is:$ (5) E (a) There are one or more statutory or contractual expenses. The total medicai service providers for payment of medical liens 01 amount cIaimed under these liens ls: $ .In satisfaction full flan claims of their (he ilenholders have agreed toaccept thetote!sum of: S l . I {Provide requested Information on each Ilanholder and certain other medical service providers beiow ) (b)The name of each medlea! servlce provider that furnished care and treatment to claimant and (1) has a lien tor alt or any part of the charges or (2) was paid (or will be paid from the proceeds) by petliloner for which petitioner requests reimbursement: the amounts charged and paid; the amount of negotiated reduction or charges. Ir any: and the amount to be paid from the proceeds of the settiement or judgment to each provider are as follows: (i)(A) Provider (name): (B) Address: (C) Amount charged: s (H) (D) (E) (F) (A) Amount paid (whether or not by Negotiated reduction. Amount to Provlder (name). Ifany. insurance): be paid from proceeds s of setflement orjudgment: 5 (:3) ( ) (B) Address: (C) Amount charged: 5 (D) Amount paid (whether or not by insurance): s ( ) (E) Negotiated reduction. Ifany: s ( ) Amount be paid from proceedsof setiiement orjudgment:$ a (F) to Contlnued 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 ls requested In Rem 13b(‘l) above. You may use form MC-350(A-13b(5)) for (his purpose.) I MC-BSO [Rem Jammy l,201-1} PETITION TO APPROVE COMPROMISE 0F DISPUTED CLAiM ”9‘5“” OR PENDlNG ACT10N OR DISPOSITION 0F PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Mlscel!aneous) M0350 CASE NAM E: CASE NUMSER: —|n Re Daniel Mendez. $— Jr. 14.The cialmant's attorney's fees and all other expenses (except medical expanses). including expenses advanced by claimant's attorney or pald or incurred by petitioner to be reimbursed from proceeds of settiement or udgment _ a. Totalamount forwhich court approva! of attorney's fees Isrequested: fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request, Including (If a discussion or applicable factors listed in rule ?.955(b) of the Cal. Rules of Court Respond to Item 18am) on page 7 and attacha copy of any agreement as Attachment written attorney fee 1 8a.) b. The expense (other than medIcal expenses) have bean incurred or paid. are reasonable, resulted following additional Items or or accident. and should be paid out of claimant‘s share of the proceeds of the settlement or Judgment: from the Incident LLelm Payees (namesl Amounts 3 investigation Thomas Professional Investigation s 300.00 Asset invesllgation and Report USA ExpreSS Legal Support s 275.00 Death Certificates Fresno County Recorder 14.00 s Notary The UPS Store s 10.00 $ $ $ . $ $ $ Continued on Attachment 14b. Total: 599.00 s 15. Reimbursement of expenses paid by petitioner a. b, a has paid none of the ciaimant‘s expenses listed in items 13 and 14 forwhich reimbursement Is requested. Petitioner has paid (or become obligated to pay) the following tota! amounts of the cIaImant's expenses for which Petitioner reimbursement ls requested. (1) (2) E E Medicalexpensesllstedlnitem 13: Attorney‘s fees Included in amount shown In Item 14a: the total fee $ $ (3) [:3 Other expenses inciuded inthatoialshownlnltem 14b: $ Total: $| I (Attach proofs of (he expenses Incurred and payments made or obligations Iopay incurred, or invoices, 9.g., bills canceled checks, credit card statements, explanations of benefits {rom Insurers, etc.) 16‘ Net balance of proceeds for thelclaimant The balance of theproceeds of the proposed settlemenl arjudgment remainingforthe claimant afterpayment of aH requested feesand expenses is: $161 382.00 17. Summary a. Gross amount of proceeds of settlement or iudgmentfor claimant: s 83,333.33 b. Medical expenses to be paid from proceedsof settiement orjudgment: S 0 c. be paid from proceeds of settiement or Attorney's fees to judgment: $ 20,752.33 d. Expenses (other than medicauto be paid from proceeds or settlement or judgment: 599.00 3 e. f. Total offees and (add (b), (c), expenses and (co): tobe paid 1mm proceeds of settlement Baiance of proceeds of settlement or judgment avaliabfe fees and expenses (subtract(e)from (5)): for orjudgmem claimant after payment of ' all 3 (3M) _ s 61,982.00 MC'SW‘RW'WW" "”1” ?ETIT!ON TO APPROVE COMPROMSE OF DISPUTED CLAIM "”6”“ OR PENDING ACTSON 0R DISPOSITION OF PROCEEDS OF JUDGMENT FOR M?NOR OR PERSON WJTH A D!SABILITY {Mlscellaneous} CASE NAME: MC-350 CASE N UMBER? —ln Re Daniel Mendez, Jr. 18. information about attorney representing or assisting petitioner a. (1) [:3 has not been represented or assisted by an attorney Petitioner In preparing thts petition or inany other way with respect to the claim asserted. (Go toItem 19.) has been represented or assisted by an attorney In preparing thls petition or with respect to the