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MC-350EX
ATTORNEY (Name, Sfate Bar number, and address): FOR COURT USE ONLY
— Timothy Pomykala SBN 109385
Attorney at Law
1451 River Park Drive, Suite 298
Sacramento, CA 95815 superior C o r n l Qf Cariforraa
TELEPHONENO.: (916)614-9090 FAX 1^0. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name): Gericka Lyd Martinoz Mendoza
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento
STREET ADDRESS 7 2 0 N i n t h S t f e c t
MAILING ADDRESS:
CITY AND ZIP CODE SacramentO, CA 95814
BRANCH NAME: 34-201
CASE NAME: CASE NUIulSER:
In re: Gericka Lyd IVIartinez Mendoza
EXPEDITED PETITION TO APPROVE:
1 ^ No hearing date is requested.
\ ^ COMPROMISE OF DISPUTED CLAIM
• COMPROMISE OF PENDING ACTION I I HEARING DATE:
• DISPOSITION OF PROCEEDS OF JUDGMENT DEPT.: TIME:
f x l Minor • Person With a Disability
NOTICE TO PETITIONERS n
You must use this form if you wish to request expedited court approval of certain (1) compromises of disputed claims of a minor,
(2) compromises of pending actions of proceedings in which a minor or a person with a disability (including a conservatee) is a party,
or (3) dispositions ofthe proceeds of judgments for a minor or person with a disability. (See Code Civ. Proc, § 372; Prob. Code,
§ 3500 et seq.) You may use this form if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f,
and either 3g(1) or 3g(2) below are true; and (3) the court does not otherwise order.
If you qualify and choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or
judgment does not qualify for expedited treatment or you choose not to use this form, you must use the Petition to Approve
Compromise of Disputed Claim or Pending Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability
(form MC-350), and the court will schedule a hearing. See Cal. Rules of Court, rules 7.950, 7.950.5, and 7.951.
1. Petitioner (/lame;.- G i n a M e n d o z a
2. Claimant (name): Gericka Lyd Martinez Mendoza
a, Address: 2511 Rose Court, Unit B
Carmichael, CA 95608
b. Date of birth: J u n e 2 0 , 1 9 9 5 c. Age. 16 d. Sex: Female e. \ ^ Minor f. Person with a disability
Expedited petition
a. The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another.
b. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust.
c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.
d. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the
claim is asserted or a party's insurance carrier.
e. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.
f. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court
has finally determined that all settling parties entered into the settlement in good faith.
g. (1) I ^ T h e judgment forthe claimant described in item 5c (exclusive of interest and costs) or the total ofthe settlement
described in items 12 and 13 payable to the claimant and all other persons named in item 13 is in the amount of
$50,000 or less; or
(2) QThe settlement described in item 12 represents payment ofthe single-person policy limits of all liability insurance
policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of
those defendants are judgment proof outside of their insurance coverage. (Describe investigation and results in
Attachment 3.)
Page 1 of 8
Form Adopted for EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Coda of Civil Procedure § 372 et seq.;
Alternative Mandatory Use Probate Code, § 3500 et seq.;
Judicial Council of Califomia CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal. Rules of Court, ailes 3.1384,
MC-350EX (New January 1, 2010] 7.101, 7.950, 7.950.5, 7.951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www.courtinfo.ca.gov
Martin Demt
(Miscellaneous)
BSENTIAF
l ORMr
CASE NmE:
C.
CASE NUMBER:
MC-350EX
- In re: Gericka Lyd Martinez Mendoza
4. Relationship Petitioner's relationship to the claimant (check all applicable boxes):
a. [ ^ P a r e n t g. Q l Other relationship (spec/^;.-
b. 1 ^ Guardian ad litem
c. 1 ^ Guardian
d. 1 ^ Conservator
e. Disabled adult claimant is a petitioner. (See instructions for items 4e and 4f below.)
f. 1 ^ Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 4f.
(If you checked item 4e or 4f, state facts on Attachment 4e or 4f 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 capacity and who does not have a
consen/ator of the estate may petition or consent to a petition. See Probate Code section 3613.)
5. Nature of claim The claim of the minor or adult person with a disability:
a. l i l Is not the subject of a pending action or proceeding. (Complete items 6-23.)
b. 1 ^ Is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
Name of court:
Case no.: Trial date: (Complete items 6-23.)
c. 1 ^ is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against
the defendants named below in the total amount (exclusive of interest and costs) of (specify):
Defendants (names);
•Additional defendants listed on Attachment 5. QjThe judgment was filed on (date):
(Attach a copy ofthe (proposed) judgment as Attachment 5c and complete items 14-23.)
F x l Incident or accident
The incident or accident occurred as follows:
a. Date March 18, 2011 Time: 3 : 5 5 p . m .
b. Place: Arden Way in Sacramento, California
c. Persons involved fnames). Gericka Lyd Martinez Mendoza, Curt Martin and City Reach, Inc.
1 ^ Continued on Attachment 6.
f i n Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe):
Motor Vehicle accident v\/herein Gericka Lyd Martinez Mendoza was in a vehicle rear-ended by
another vehicle driven by Curt Martin and owned by City Reach, Inc.
C I Continued on Attachment 7.
MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 2 of s
[Newjanuary 1.2010] CLAIM OR PENDING ACTION OR DISPOS
ON OR DISPOSITION O F P R O C E E D S O F
(21 SNMFORMV" )R OR
JUDGMENT FOR MINOR PERSON WITH A DISABILITY
OR PERSON
(Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER:
— In re: Gericka Lyd Martinez Mendoza
I X I Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Soft tissue - back and neck strain/sprain
I I Continued on Attachment 8.
9. ( X l Treatment
The claimant received the following care and treatment for the injuries described in item 8 (describe):
Kaiser performed exam, x-rays which found no fractures, and physical therapy. Dr. Michael D.
Murphy, D.C. performed chiropractic treatment.
! • Continued on Attachment 9.
10. (XI 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 attached to this petition as Attachment 10.
A new report is not necessary so long as a previous report accurately describes the claimant's current condition.)
a. I X I The claimant has recovered completely from the effects ofthe injuries described in item 8, and there are no
permanent injuries.
b. • The claimant has not recovered completely from the effects ofthe injuries described in item 8, and the following
injuries from which the claimant has not recovered are temporary (describe the remaining injuries):
I I Continued on Attachment 10b.
1^ The claimant has not recovered completely from the effects ofthe injuries described in item 8, and the following
injuries from which the claimant has not recovered are permanent (describe the pemnanent injuries):
I I Continued on Attachment 10c.
11. 1 ^ 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 ofthe 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.
12. 1X1 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 below is (specify): $ | 10,750
b. The defendants and amounts offered by each are as follows (specify):
Defendants (names) Amounts
Curt Martin/City Reach, Inc. $ 10,750
$
$
$
I I Additional defendants and amounts offered are listed on Attachment 12.
c. The terms of settlement are described on Attachment 12. (If the settlement is to be paid in installments, both the total
amount and the present value ofthe settlement must be included.)
MC.350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 3 of s
iNew January 1.2010) CLAIM OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F
gj fo^'Ji'iiffnijMy- J U D G M E N T F O R MINOR OR P E R S O N WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER:
— In re: Gericka Lyd Martinez Mendoza
13. 1X1 Settlement payments to others
a. ( ^ N o defendant named in item 12b 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. CiDBy way of settlement, one or more defendants named in item 12b 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) I I Petitioner would receive money under the proposed settlement.
(3) The settlement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
$
$
$
$
1^Additional plaintiffs or claimants and amounts are listed on Attachment 13.
(4) I ^ T h e settlement payments are apportioned between the claimant and each other plaintiff or claimant
named above on a pro rata basis, based upon the special damages claimed by each. The special
damages claimed by each other plaintiff or claimant are specified on Attachment 13.
(5) C 3 Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 13.
14. The claimant's medical expenses, including medical expenses paid by petitioner. Medicare, Medi-Cal, and private
insurers, that are to be reimbursed from proceeds of settlement or judgment
a. Totals
(1) Total expenses: $ 4,830
(2) Total amount paid (including payments by private insurance, Medi-Cal, or Medicare): $ ( 0)
(3) Total of negotiated reductions, if any: $ ( 1,905)
(4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ | 2,925
(5) Total amount of medical liens, if any: $ 2,925
(Identify each medical expense payer and the amount each paid, and explain any differences between items 14a(1), (4) and (5)
in Attachment 14a.)
(1) (XlNone ofthe claimant's medical expenses have been paid by Medicare.
(2) • M e d i c a r e paid some or all of claimant's medical expenses. In full satisfaction of its lien rights,
Medicare will be reimbursed in the amount of $
(Attach a copy of the final Med/care demand letter or letter agreement as Attachment 14b(2).)
(1) 1X1 None ofthe claimant's medical expenses have been paid by Medi-Cal.
(2) ! • Medi-Cal paid all or some or all of the claimant's medical expenses.
(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 ofthe notice and proof of its delivery is attached.
I I was filed in this matter on (dafe):
(b) 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 14c(2).)
1X1 The claimant's health plan is requesting reimbursement for medical expenses paid under
the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ | 725
(Attach statements from the plan showing expense payments and requesting reimbursement.)
( • Petitioner has paid claimant's medical expenses to be reimbursed in the amount of
(See instructions for item 16.)
MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED page4of8
CLAIM O R PENDING ACTION OR DISPOSITION O F P R O C E E D S O F
JUDGMENT F O R MINOR O R P E R S O N WITH A DISABILITY
BJENIAIFORMJ" „
(Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER:
- In re: Gericka Lyd Martinez Mendoza
14. The claimant's medical expenses, including medical expenses paid by petitioner. Medicare, Medi-Cal, and private
insurers, that are to be reimbursed from proceeds of settlement or judgment
f. 1X1 There are one or more liens from medical service providers for payment of claimant's medical expenses.
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ 2,200
g. (Se/ecf(i;or(2)be;ow.j
(1) [ ^ L a t e s t statements from all medical service providers are attached as Attachment 14g.
(2) I ^ A I I medical expenses have been paid by private insurance. Medicare, or Medi-Cal.
15. The claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by
petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment
Total amount of attorney's fees for which court approval is requested: $ | 2,547
(if fees are requested, attach as Attachment 15a a declaration from the attomey explaining the basis forthe request, including
a discussion of applicable factors listed in rule 7.955(b) ofthe Cal. Rules of Court. Include a copy of any written attomey fee
agreement in Attachment 15a.)
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 or reimbursed out of claimant's share of the proceeds of the settlement or
judgment:
Items Payees (names) Amounts
Filing fee for Petition Sacramento Superior Court $ 395
Fee for Order appointing G.A.L. Sacramento Superior Court $ 40
Medical Records Casey Corporation $ 124
$
$
$
$
$
$
$
$
$
Total: $ 559
! • Continued on Attachment 15b.
c. ( • Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based
on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 15c.
16. Reimbursement of expenses paid by petitioner
a. 1X1 Petitioner has paid none ofthe claimant's expenses listed in items 14 and 15 for which reimbursement is requested.
b. ! • Petitioner has paid the following total amounts of the claimant's expenses for which reimbursement is requested.
(1) [^Medical expenses listed in item 14: $
(2) Ci]lAttorney's fees included in the total fee amount shown in item 15a: $
(3) I ^ O t h e r expenses included in the total shown in item 15b: $
(Attach proofs ofthe expenses incurred and payments made, e.g., bills or Total: $
invoices, canceled checks, credit card statements, explanations of benefits
from insurers, etc.)
17. Net balance of proceeds for the claimant
The balance ofthe proceeds ofthe proposed settlement or judgment remaining forthe claimant after payment or
reimbursement of all requested fees and expenses is (specify): $ 4,719
MC-350EX E X P E D I T E D PETITION TO A P P R O V E COMPROMISE O F DISPUTED Page 5 ot 8
(New January 1, 2010)
CLAIM OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F
f7~S] Mnrttnl!)cflit^
JUDGMENT F O R MINOR OR P E R S O N WITH A DISABILITY
raESSENIIAlPORMf
(Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER;
— In re: Gericka Lyd Martinez Mendoza
18. Summary
a. Gross amount of proceeds of settlement or judgment for claimant: 10,750
b. Medical expenses to be paid from proceeds of settlement or
judgment: $ 2,925
c. Attorney's fees to be paid from proceeds of settlement or
judgment: $ 2,547
d. Expenses (other than medical) to be paid from proceeds
of settlement or judgment: $ _ 559
e. Total of fees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c), and (d)): $ (- 6,031)
f. Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (e) from (a)): 4,719
19. Information about attorney representing or assisting petitioner
a. The attorney ( X I is not is representing or employed by any other party involved in this matter.
(If you answered "is," identify the other party and explain the relationship in Attachment 19a. If the other party is a defendant,
you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1
and Cal. Rules of Court, mle 7.950.5(a)(6).)
b. The attorney 1X1 has neither received nor expects to receive [^has received or expects 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 "has received or expects to receive," identify the person who paid or will pay the fees or other
compensation, the amounts paid or to be paid, and the dates of payment or expected payment):
From Whom Paid or Expected (name): Date Paid or Expected Amount Paid or Expected
$
$
$
$
$
$
$
Total: $
I I Continued on Attachment 19b.
20. Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance ofthe proceeds ofthe 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.:
(1) • $ ofthe 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 consen/atee. The money
or other property is specified in Attachment 20a(1).
(2) • Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability.
Petitioner requests authority to deposit or invest $ of the money or other
property to be paid or delivered under 20a(1) with one or more financial 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 20a(2).
MC-350EX E X P E D I T E D PETITION TO A P P R O V E COMPROMISE O F DISPUTED Page 6 ot 8
[Newjanuary 1. 2010]
CLAIM OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F
if Jjl Manin Dean's
JUDGMENT F O R MINOR OR P E R S O N WITH A DISABILITY
l^B5ENmiF0RM5" (Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER:
— In re: Gericka Lyd Martinez Mendoza
20. Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds ofthe 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
(3) Q l Petitioner proposes that all or a portion ofthe proceeds not become part ofthe guardianship or
conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows
(check all that apply):
(a) 1 ^ $ 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 20a(3).
(b) Q l $ will be invested in a single-premium deferred annuity subject to
withdrawal only on order ofthe court. The terms and conditions ofthe annuity are specified in
Attachment 20a(3).
(c) 1 ^ $ will be transferred to a custodian for the benefit of the minor under the
California Uniform Transfers to Minors Act. The name and address ofthe proposed custodian
and the property to be transferred are specified in Attachment 20a(3).
b. 1 ^ 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 ofthe proceeds ofthe settlement or judgment be disbursed as follows (check all
that apply):
(1) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability
will be 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 20b(1).
(2) 1 ^ $ 4 , 7 1 9 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 20b(2).
(3) $ of money will be invested in a single-premium deferred annuity, subject to
withdrawal only upon the authorization ofthe court. The terms and conditions ofthe annuity are specified
in Attachment 20b(3).
(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 ofthe
parent and the money or other property to be delivered are specified in Attachment 20b(4). (Value of minor's
entire estate, including the money or property to be delivered, must not exceed $5,000.)
(5) • $ 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 20b(5).
(6) C!3 $ 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 proposed conditions are specified
on Attachment 20b(6). (Value must not exceed $20,000.)
(7) 1 ^ $ 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 20b(7).
(8) • $ 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 Code section 3611(h).
(9) • $ will be paid or transferred to the adult person with a disability. The money or other
property is specified in Attachment 20b(9).
• Continued on Attachment 20.
MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page Tot 8
[Newjanuary 1.20101 C L A M OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
ES5ENIAIPDRM5"'
(Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER:
— Gericka Lyd Martinez Mendoza
21. 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 ofthe 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.
22. 1X1 Additional orders
Petitioner requests the following additional orders (specify and explain):
a. ) That Petitioner is authorized and directed to execute any and all documents reasonably
necessary to carry out the terms of the settlement including but not limtited to a full and final release
of all claims.
b. ) That the insurance company paying the settlement shall pay the $10,750 settlment in a check or
draft made payable to: "Gina Mendoza, as guardian ad litem for Gericka Lyd Martinez Mendoza and
Timothy Pomykala, her attorney" and deliver said check or draft to the attorney for deposit in the
Attorney-Client Trust Account and disbursement in accordance with paragraphs 13,14,15,17,18 and
20 and Attachment 14 of this Petition.
1^ Continued on Attachment 22.
23. Number of pages attached: 16
Date:
Timothy Pomykala
(TYPE OR PRINT NAME OF ATTORNEY) / / (SIGNATURE OF ATTORNEY)
declare under penalty of perjury under the laws ofthe State of California that the foregoing is true and correct.
Date: / T .
G i n a Mf»nrio7a
(TYPE OR PRINT NAME OF PETITIONER) (SIGNATUREOF PETITIONER)
MC.350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED pagesots
January 1,2010) CLAIM O R PENDING ACTION OR DISPOSITION O F P R O C E E D S O F
J U D G M E N T F O R MINOR OR P E R S O N WITH A DISABILITY
I ESSENTIAL FORMS™ „
(Miscellaneous)
• MC-025
SHORT TITLE: CASE NUMBER;
- In re: Gericka Lyd Martinez Mendoza
ATTACHMENT f/Vumber;: 1Q_
(This Attachment may be used with any Judicial Council fonv.)
See doctor's reports regarding Gericka Lyd Martinez Mendoza's medical condition attached hereto.
(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of.
Attachment are made under penalty of perjury.) (Add pages as required)
Form Approved for Optional Use ATTACHMENT www.courtinfo.ca.gov
Judicial Council of Califomia
MC-025 [Rev. July 1, 2009) to Judicial Council Form
MartinDeaii'S
BSENTA
I l FORMS"
•
KAISER FOUNDATION SAC-HOSPITAL MENDOZA.GERICKA L
\l\r 2025 MORSE AVENUE MRN: 110011694268
HOSPITAL DOB: 6/20/1995, Sex: F
SACRAT^ENTG. CA 95825-2115 Adm:3/19/2011. D/C:3/19/2011
Emergency Department Records
Diaqnoses
Diagnosis Conimenl AcJfled By Time Acided Team Role ED Provider? Provider Specialty
PAIN. BACK. Hernando (M.D.) 3/19/11 09:38 Attending Y Emergency Medicine
G^rzon PM Provider
CAUSE OF INJURY. MVA Hernando (M.D.) 3/19/11 09:38 Attending Y Emergency Medicine
Garzon PM Provider
ED Disposition
Dischargc/DI Discharge Disposition; HOME
smiss to
Home
ED NURSING
E D N u r s i n g s i g n e d b v M o i s e v e n k o , A n n a (R.N.) at 03/19/11 2142
Author: Moiseyenko. AJina (R.N.) Seivice: (none) Author Type; REGISTERED NURSE
Filed: 03/19/11 2142 Note Time; 03/19/11 2142
Gericka L Mendoza (MRN# 110011694268) received verbal discharge instructions by Dr. Garzon.
Electionri-.iilly signed by Moissyenko. Anna (R N.) on 03/19/11 2142
ED P R O V I D E R N O T E S
ED P r o v i d e r N o t e s s i g n e d b y G a r z o n , H e r n a n d o (M.D.) at 03/19/11 2200
Author; Garzon, Hernando (M.D.) Service; (none) Author Type: Physician
Filed: 03/19/11 2200 Note Time: 03/19/11 2154
EMERGENCY DEPARTMENT RECORD
Gericka L Mendoza is a 15 Y female who complains of MOTOR VEHICLE ACCIDENT
HPI: Pt was a belted passenger in Honda Accord struck from behind at low speed on surface streets
yesterday. Car was driven from scene. Only symptom at the time was mild upper back pain. Pt states that she
and her father, the driver, were going to wait and see the doctor on Monday, but decided to get checked today
because pain seems slightly worse. No radiation of pain which is biiat and paraspinal in the upper back region.
No SOB, CP, neck pain, headache. No other sx.pain worse with movements.
Primary Care Provider: MARIA NORMA VIC A. BANEZ MD, MEDICAL DOCTOR
Past Medical History:
No past medical history on file.
Past Surgical History;
No past surgical history on file.
Patient Active Problem List:
DYSPNEA
ASTHMA, EXERCISE INDUCED
00013
KAISER FOUNDATION SAC-HOSPITAL MENDOZA.GERICKA L
2025 MORSE AVENUE MRN: 110011694288
HOSPITAL DOB: 6/20/1995, Sex: F
SACRAMENTO, CA 95825-2115 Adm:3/19/2011. D/C:3/19/2011
ED PROVIDER NOTES (continued)
No active medications on file as of 03/19/2011
ALLERGIES: No known allergies
History
Social History
• Marital Status: Single/Never Married
Spouse Name: N/A
Number of Children: N/A
• Years of Education: N/A
Occupational History
• Not on file.
Social History- Main Topics
• Tobacco Use: Never
• Alcohol Use: Not on file
• Drug Use: Not on file
• Sexually Active: Not on file
other Topics Concern
• Not on file
Social History Narrative
• No narrative on file
Review of Systems
Constitutional: Negative for fever.
HENT: Negative for headaches.
Cardiovascular: Negative for chest pain.
Respiratory: Is not experiencing shortness of breath.
Gastrointestinal: Negative for abdominal pain.
Genitourinary; Negative for flank pain.
Musculoskeletal; Positive for back pain. Negative for myalgias, neck pain, joint pain and falls.
Neurological: Negative for loss of consciousness.
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No
distress.
BP 108/57 I Pulse 55 | Temp 97.3 "F (36.3 °C) | Resp 17 | Wt 46.267 kg (102 Ib) | Sp02 100%
HENT:
Head: Normocephalic and atraumatic.
Nose: Nose normal.
Mouth/Throat: Oropharynx is clear and moist.
Eyes: Extraocular motions are normal. Pupils are equal, round, and reactive to light. No scleral icterus.
Neck: Normal range of motion. Neck supple. No JVD present. No thyromegaly present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop and no friction
rub.
00014
c
KAISER FOUNDATION SAC-HOSPITAL MENDOZA.GERICKAL
2025 MORSE AVENUE MRN: 110011694268
HOSPITAL DOB: 6/20/1995, Sex: F
SACRAMENTO, CA 95825-2115 Adm:3/19/2011, D/C:3/19/2011
ED PROVIDER NOTES (continued)
No murmur h6ard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She
has no rales.
No seatbelt mark
Abdominal: Soft. Bowel sounds are nomial. She exhibits no distension. No tenderness. She has no rebound
and no guarding.
Musculoskeletal: Normal range of motion. She exhibits no edema.
Mild para spinal thoracic back TTP .with no bruising or bony tenderness.
Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit.
Skin: Skin is warm and dry. No rash noted.
ED COURSE: No treatment necessary.
MDM: Mild upper back pain 1 day s/p MVA. Given mild sx and normal exam, no need for x-rays as significant
injury not suspected. Pt advised of findings and OTC meds and rest advised. Will f/u with PCP prn.
IMPRESSlON/PLAN:
Dx: PAIN, BACK, (primary encounter diagnosis)
Comments:
Dx: CAUSE OF INJURY. MVA
Comments:
The patient's current list of medications was reviewed and reconciled.
HERNANDO GARZON MD
Eleclronir;.-5ily signed by Garzon. Hernando (M.D.) on 03/19'11 2200
Notes from linked episodes
•* None **
Discharge Instructions Mendoza, Gericka L (MR #110011694268)
Dale Status User User Type Discharge Note
03/19/11 2139 Pended Garzon, Hernando (M.D.) Physician Original
Note:
(Do NOT put PATIENT INSTRUCTIONS In this space! Clerical Instructions only.)
DC Clerk to do the following:
00015
KAISER PERMAMENTE^LG-BiGHORN MENDOZA.GERICKAL
1 i_ixivir^iM 9201 BIG HORN BLVD MRN: 110011694268
DOB: 6/20/1995, Sex: F
ELK GROVE, CA 95758-1240 Enc. Date:04/08/11
Encounter Information (continued
ntinued)
|.1iDate&!T:imei:::[:;:i::1:::::::i::1.;^
4/8/2011 4:30 PM MARIA NORMA VIC A. BANEZ MD Elg-Pedl >Big Horn ELGA
Visit Notes
ARLETTE ARRIAGA WIA Fri Apr 8, 2011 4:38 PM
Electronically signed by ARLETTE ARRIAGA MA on Fri Apr 8, 2011 4:38 PM
Progress Notes
Banez, Maria Norma Vic A. (M.D.) Physician 4/8/11 07:54 PM Signed
SUBJECTIVE:
Gericka L Mendoza is a 15 Y female who was in a motor vehicle accident 3/18/2011 She was a passenger in
the front seat, with shoulder belt, with seat belt. Description of impact: rear-ended. The patient was tossed
forwards and backwards during the impact. The patient denies a history of loss of consciousness, head injury,
striking chest/abdomen on steering wheel, nor extremities or broken glass in the vehicle.
Has complaints of pain at upper back 1 day after the accident, seen in the ED on 3/19/2011. Per ED note,
other than mild TENDER TO PALPATION to upper back, patient otherwise normal. Hence no imaging done.
Preview
MC-350EX ATTORNEY (Name, Sfate Bar number, and address): FOR COURT USE ONLY — Timothy Pomykala SBN 109385 Attorney at Law 1451 River Park Drive, Suite 298 Sacramento, CA 95815 superior C o r n l Qf Cariforraa TELEPHONENO.: (916)614-9090 FAX 1^0. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): Gericka Lyd Martinoz Mendoza SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento STREET ADDRESS 7 2 0 N i n t h S t f e c t MAILING ADDRESS: CITY AND ZIP CODE SacramentO, CA 95814 BRANCH NAME: 34-201 CASE NAME: CASE NUIulSER: In re: Gericka Lyd IVIartinez Mendoza EXPEDITED PETITION TO APPROVE: 1 ^ No hearing date is requested. \ ^ COMPROMISE OF DISPUTED CLAIM • COMPROMISE OF PENDING ACTION I I HEARING DATE: • DISPOSITION OF PROCEEDS OF JUDGMENT DEPT.: TIME: f x l Minor • Person With a Disability NOTICE TO PETITIONERS n You must use this form if you wish to request expedited court approval of certain (1) compromises of disputed claims of a minor, (2) compromises of pending actions of proceedings in which a minor or a person with a disability (including a conservatee) is a party, or (3) dispositions ofthe proceeds of judgments for a minor or person with a disability. (See Code Civ. Proc, § 372; Prob. Code, § 3500 et seq.) You may use this form if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and either 3g(1) or 3g(2) below are true; and (3) the court does not otherwise order. If you qualify and choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or judgment does not qualify for expedited treatment or you choose not to use this form, you must use the Petition to Approve Compromise of Disputed Claim or Pending Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing. See Cal. Rules of Court, rules 7.950, 7.950.5, and 7.951. 1. Petitioner (/lame;.- G i n a M e n d o z a 2. Claimant (name): Gericka Lyd Martinez Mendoza a, Address: 2511 Rose Court, Unit B Carmichael, CA 95608 b. Date of birth: J u n e 2 0 , 1 9 9 5 c. Age. 16 d. Sex: Female e. \ ^ Minor f. Person with a disability Expedited petition a. The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another. b. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust. c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement. d. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier. e. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier. f. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court has finally determined that all settling parties entered into the settlement in good faith. g. (1) I ^ T h e judgment forthe claimant described in item 5c (exclusive of interest and costs) or the total ofthe settlement described in items 12 and 13 payable to the claimant and all other persons named in item 13 is in the amount of $50,000 or less; or (2) QThe settlement described in item 12 represents payment ofthe single-person policy limits of all liability insurance policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of those defendants are judgment proof outside of their insurance coverage. (Describe investigation and results in Attachment 3.) Page 1 of 8 Form Adopted for EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Coda of Civil Procedure § 372 et seq.; Alternative Mandatory Use Probate Code, § 3500 et seq.; Judicial Council of Califomia CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal. Rules of Court, ailes 3.1384, MC-350EX (New January 1, 2010] 7.101, 7.950, 7.950.5, 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www.courtinfo.ca.gov Martin Demt (Miscellaneous) BSENTIAF l ORMr CASE NmE: C. CASE NUMBER: MC-350EX - In re: Gericka Lyd Martinez Mendoza 4. Relationship Petitioner's relationship to the claimant (check all applicable boxes): a. [ ^ P a r e n t g. Q l Other relationship (spec/^;.- b. 1 ^ Guardian ad litem c. 1 ^ Guardian d. 1 ^ Conservator e. Disabled adult claimant is a petitioner. (See instructions for items 4e and 4f below.) f. 1 ^ Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 4f. (If you checked item 4e or 4f, state facts on Attachment 4e or 4f 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 capacity and who does not have a consen/ator of the estate may petition or consent to a petition. See Probate Code section 3613.) 5. Nature of claim The claim of the minor or adult person with a disability: a. l i l Is not the subject of a pending action or proceeding. (Complete items 6-23.) b. 1 ^ Is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim. Name of court: Case no.: Trial date: (Complete items 6-23.) c. 1 ^ is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against the defendants named below in the total amount (exclusive of interest and costs) of (specify): Defendants (names); •Additional defendants listed on Attachment 5. QjThe judgment was filed on (date): (Attach a copy ofthe (proposed) judgment as Attachment 5c and complete items 14-23.) F x l Incident or accident The incident or accident occurred as follows: a. Date March 18, 2011 Time: 3 : 5 5 p . m . b. Place: Arden Way in Sacramento, California c. Persons involved fnames). Gericka Lyd Martinez Mendoza, Curt Martin and City Reach, Inc. 1 ^ Continued on Attachment 6. f i n Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe): Motor Vehicle accident v\/herein Gericka Lyd Martinez Mendoza was in a vehicle rear-ended by another vehicle driven by Curt Martin and owned by City Reach, Inc. C I Continued on Attachment 7. MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 2 of s [Newjanuary 1.2010] CLAIM OR PENDING ACTION OR DISPOS ON OR DISPOSITION O F P R O C E E D S O F (21 SNMFORMV" )R OR JUDGMENT FOR MINOR PERSON WITH A DISABILITY OR PERSON (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER: — In re: Gericka Lyd Martinez Mendoza I X I Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Soft tissue - back and neck strain/sprain I I Continued on Attachment 8. 9. ( X l Treatment The claimant received the following care and treatment for the injuries described in item 8 (describe): Kaiser performed exam, x-rays which found no fractures, and physical therapy. Dr. Michael D. Murphy, D.C. performed chiropractic treatment. ! • Continued on Attachment 9. 10. (XI 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 attached to this petition as Attachment 10. A new report is not necessary so long as a previous report accurately describes the claimant's current condition.) a. I X I The claimant has recovered completely from the effects ofthe injuries described in item 8, and there are no permanent injuries. b. • The claimant has not recovered completely from the effects ofthe injuries described in item 8, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries): I I Continued on Attachment 10b. 1^ The claimant has not recovered completely from the effects ofthe injuries described in item 8, and the following injuries from which the claimant has not recovered are permanent (describe the pemnanent injuries): I I Continued on Attachment 10c. 11. 1 ^ 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 ofthe 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. 12. 1X1 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 below is (specify): $ | 10,750 b. The defendants and amounts offered by each are as follows (specify): Defendants (names) Amounts Curt Martin/City Reach, Inc. $ 10,750 $ $ $ I I Additional defendants and amounts offered are listed on Attachment 12. c. The terms of settlement are described on Attachment 12. (If the settlement is to be paid in installments, both the total amount and the present value ofthe settlement must be included.) MC.350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 3 of s iNew January 1.2010) CLAIM OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F gj fo^'Ji'iiffnijMy- J U D G M E N T F O R MINOR OR P E R S O N WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER: — In re: Gericka Lyd Martinez Mendoza 13. 1X1 Settlement payments to others a. ( ^ N o defendant named in item 12b 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. CiDBy way of settlement, one or more defendants named in item 12b 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) I I Petitioner would receive money under the proposed settlement. (3) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts $ $ $ $ 1^Additional plaintiffs or claimants and amounts are listed on Attachment 13. (4) I ^ T h e settlement payments are apportioned between the claimant and each other plaintiff or claimant named above on a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other plaintiff or claimant are specified on Attachment 13. (5) C 3 Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 13. 14. The claimant's medical expenses, including medical expenses paid by petitioner. Medicare, Medi-Cal, and private insurers, that are to be reimbursed from proceeds of settlement or judgment a. Totals (1) Total expenses: $ 4,830 (2) Total amount paid (including payments by private insurance, Medi-Cal, or Medicare): $ ( 0) (3) Total of negotiated reductions, if any: $ ( 1,905) (4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ | 2,925 (5) Total amount of medical liens, if any: $ 2,925 (Identify each medical expense payer and the amount each paid, and explain any differences between items 14a(1), (4) and (5) in Attachment 14a.) (1) (XlNone ofthe claimant's medical expenses have been paid by Medicare. (2) • M e d i c a r e paid some or all of claimant's medical expenses. In full satisfaction of its lien rights, Medicare will be reimbursed in the amount of $ (Attach a copy of the final Med/care demand letter or letter agreement as Attachment 14b(2).) (1) 1X1 None ofthe claimant's medical expenses have been paid by Medi-Cal. (2) ! • Medi-Cal paid all or some or all of the claimant's medical expenses. (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 ofthe notice and proof of its delivery is attached. I I was filed in this matter on (dafe): (b) 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 14c(2).) 1X1 The claimant's health plan is requesting reimbursement for medical expenses paid under the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ | 725 (Attach statements from the plan showing expense payments and requesting reimbursement.) ( • Petitioner has paid claimant's medical expenses to be reimbursed in the amount of (See instructions for item 16.) MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED page4of8 CLAIM O R PENDING ACTION OR DISPOSITION O F P R O C E E D S O F JUDGMENT F O R MINOR O R P E R S O N WITH A DISABILITY BJENIAIFORMJ" „ (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER: - In re: Gericka Lyd Martinez Mendoza 14. The claimant's medical expenses, including medical expenses paid by petitioner. Medicare, Medi-Cal, and private insurers, that are to be reimbursed from proceeds of settlement or judgment f. 1X1 There are one or more liens from medical service providers for payment of claimant's medical expenses. In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ 2,200 g. (Se/ecf(i;or(2)be;ow.j (1) [ ^ L a t e s t statements from all medical service providers are attached as Attachment 14g. (2) I ^ A I I medical expenses have been paid by private insurance. Medicare, or Medi-Cal. 15. The claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment Total amount of attorney's fees for which court approval is requested: $ | 2,547 (if fees are requested, attach as Attachment 15a a declaration from the attomey explaining the basis forthe request, including a discussion of applicable factors listed in rule 7.955(b) ofthe Cal. Rules of Court. Include a copy of any written attomey fee agreement in Attachment 15a.) 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 or reimbursed out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts Filing fee for Petition Sacramento Superior Court $ 395 Fee for Order appointing G.A.L. Sacramento Superior Court $ 40 Medical Records Casey Corporation $ 124 $ $ $ $ $ $ $ $ $ Total: $ 559 ! • Continued on Attachment 15b. c. ( • Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 15c. 16. Reimbursement of expenses paid by petitioner a. 1X1 Petitioner has paid none ofthe claimant's expenses listed in items 14 and 15 for which reimbursement is requested. b. ! • Petitioner has paid the following total amounts of the claimant's expenses for which reimbursement is requested. (1) [^Medical expenses listed in item 14: $ (2) Ci]lAttorney's fees included in the total fee amount shown in item 15a: $ (3) I ^ O t h e r expenses included in the total shown in item 15b: $ (Attach proofs ofthe expenses incurred and payments made, e.g., bills or Total: $ invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) 17. Net balance of proceeds for the claimant The balance ofthe proceeds ofthe proposed settlement or judgment remaining forthe claimant after payment or reimbursement of all requested fees and expenses is (specify): $ 4,719 MC-350EX E X P E D I T E D PETITION TO A P P R O V E COMPROMISE O F DISPUTED Page 5 ot 8 (New January 1, 2010) CLAIM OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F f7~S] Mnrttnl!)cflit^ JUDGMENT F O R MINOR OR P E R S O N WITH A DISABILITY raESSENIIAlPORMf (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER; — In re: Gericka Lyd Martinez Mendoza 18. Summary a. Gross amount of proceeds of settlement or judgment for claimant: 10,750 b. Medical expenses to be paid from proceeds of settlement or judgment: $ 2,925 c. Attorney's fees to be paid from proceeds of settlement or judgment: $ 2,547 d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ _ 559 e. Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): $ (- 6,031) f. Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): 4,719 19. Information about attorney representing or assisting petitioner a. The attorney ( X I is not is representing or employed by any other party involved in this matter. (If you answered "is," identify the other party and explain the relationship in Attachment 19a. If the other party is a defendant, you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1 and Cal. Rules of Court, mle 7.950.5(a)(6).) b. The attorney 1X1 has neither received nor expects to receive [^has received or expects 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 "has received or expects to receive," identify the person who paid or will pay the fees or other compensation, the amounts paid or to be paid, and the dates of payment or expected payment): From Whom Paid or Expected (name): Date Paid or Expected Amount Paid or Expected $ $ $ $ $ $ $ Total: $ I I Continued on Attachment 19b. 20. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance ofthe proceeds ofthe 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.: (1) • $ ofthe 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 consen/atee. The money or other property is specified in Attachment 20a(1). (2) • Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ of the money or other property to be paid or delivered under 20a(1) with one or more financial 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 20a(2). MC-350EX E X P E D I T E D PETITION TO A P P R O V E COMPROMISE O F DISPUTED Page 6 ot 8 [Newjanuary 1. 2010] CLAIM OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F if Jjl Manin Dean's JUDGMENT F O R MINOR OR P E R S O N WITH A DISABILITY l^B5ENmiF0RM5" (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER: — In re: Gericka Lyd Martinez Mendoza 20. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance of the proceeds ofthe 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 (3) Q l Petitioner proposes that all or a portion ofthe proceeds not become part ofthe guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply): (a) 1 ^ $ 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 20a(3). (b) Q l $ will be invested in a single-premium deferred annuity subject to withdrawal only on order ofthe court. The terms and conditions ofthe annuity are specified in Attachment 20a(3). (c) 1 ^ $ will be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address ofthe proposed custodian and the property to be transferred are specified in Attachment 20a(3). b. 1 ^ 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 ofthe proceeds ofthe settlement or judgment be disbursed as follows (check all that apply): (1) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability will be 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 20b(1). (2) 1 ^ $ 4 , 7 1 9 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 20b(2). (3) $ of money will be invested in a single-premium deferred annuity, subject to withdrawal only upon the authorization ofthe court. The terms and conditions ofthe annuity are specified in Attachment 20b(3). (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 ofthe parent and the money or other property to be delivered are specified in Attachment 20b(4). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) (5) • $ 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 20b(5). (6) C!3 $ 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 proposed conditions are specified on Attachment 20b(6). (Value must not exceed $20,000.) (7) 1 ^ $ 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 20b(7). (8) • $ 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 Code section 3611(h). (9) • $ will be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 20b(9). • Continued on Attachment 20. MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page Tot 8 [Newjanuary 1.20101 C L A M OR PENDING ACTION OR DISPOSITION O F P R O C E E D S O F JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ES5ENIAIPDRM5"' (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER: — Gericka Lyd Martinez Mendoza 21. 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 ofthe 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. 22. 1X1 Additional orders Petitioner requests the following additional orders (specify and explain): a. ) That Petitioner is authorized and directed to execute any and all documents reasonably necessary to carry out the terms of the settlement including but not limtited to a full and final release of all claims. b. ) That the insurance company paying the settlement shall pay the $10,750 settlment in a check or draft made payable to: "Gina Mendoza, as guardian ad litem for Gericka Lyd Martinez Mendoza and Timothy Pomykala, her attorney" and deliver said check or draft to the attorney for deposit in the Attorney-Client Trust Account and disbursement in accordance with paragraphs 13,14,15,17,18 and 20 and Attachment 14 of this Petition. 1^ Continued on Attachment 22. 23. Number of pages attached: 16 Date: Timothy Pomykala (TYPE OR PRINT NAME OF ATTORNEY) / / (SIGNATURE OF ATTORNEY) declare under penalty of perjury under the laws ofthe State of California that the foregoing is true and correct. Date: / T . G i n a Mf»nrio7a (TYPE OR PRINT NAME OF PETITIONER) (SIGNATUREOF PETITIONER) MC.350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED pagesots January 1,2010) CLAIM O R PENDING ACTION OR DISPOSITION O F P R O C E E D S O F J U D G M E N T F O R MINOR OR P E R S O N WITH A DISABILITY I ESSENTIAL FORMS™ „ (Miscellaneous) • MC-025 SHORT TITLE: CASE NUMBER; - In re: Gericka Lyd Martinez Mendoza ATTACHMENT f/Vumber;: 1Q_ (This Attachment may be used with any Judicial Council fonv.) See doctor's reports regarding Gericka Lyd Martinez Mendoza's medical condition attached hereto. (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of. Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use ATTACHMENT www.courtinfo.ca.gov Judicial Council of Califomia MC-025 [Rev. July 1, 2009) to Judicial Council Form MartinDeaii'S BSENTA I l FORMS" • KAISER FOUNDATION SAC-HOSPITAL MENDOZA.GERICKA L \l\r 2025 MORSE AVENUE MRN: 110011694268 HOSPITAL DOB: 6/20/1995, Sex: F SACRAT^ENTG. CA 95825-2115 Adm:3/19/2011. D/C:3/19/2011 Emergency Department Records Diaqnoses Diagnosis Conimenl AcJfled By Time Acided Team Role ED Provider? Provider Specialty PAIN. BACK. Hernando (M.D.) 3/19/11 09:38 Attending Y Emergency Medicine G^rzon PM Provider CAUSE OF INJURY. MVA Hernando (M.D.) 3/19/11 09:38 Attending Y Emergency Medicine Garzon PM Provider ED Disposition Dischargc/DI Discharge Disposition; HOME smiss to Home ED NURSING E D N u r s i n g s i g n e d b v M o i s e v e n k o , A n n a (R.N.) at 03/19/11 2142 Author: Moiseyenko. AJina (R.N.) Seivice: (none) Author Type; REGISTERED NURSE Filed: 03/19/11 2142 Note Time; 03/19/11 2142 Gericka L Mendoza (MRN# 110011694268) received verbal discharge instructions by Dr. Garzon. Electionri-.iilly signed by Moissyenko. Anna (R N.) on 03/19/11 2142 ED P R O V I D E R N O T E S ED P r o v i d e r N o t e s s i g n e d b y G a r z o n , H e r n a n d o (M.D.) at 03/19/11 2200 Author; Garzon, Hernando (M.D.) Service; (none) Author Type: Physician Filed: 03/19/11 2200 Note Time: 03/19/11 2154 EMERGENCY DEPARTMENT RECORD Gericka L Mendoza is a 15 Y female who complains of MOTOR VEHICLE ACCIDENT HPI: Pt was a belted passenger in Honda Accord struck from behind at low speed on surface streets yesterday. Car was driven from scene. Only symptom at the time was mild upper back pain. Pt states that she and her father, the driver, were going to wait and see the doctor on Monday, but decided to get checked today because pain seems slightly worse. No radiation of pain which is biiat and paraspinal in the upper back region. No SOB, CP, neck pain, headache. No other sx.pain worse with movements. Primary Care Provider: MARIA NORMA VIC A. BANEZ MD, MEDICAL DOCTOR Past Medical History: No past medical history on file. Past Surgical History; No past surgical history on file. Patient Active Problem List: DYSPNEA ASTHMA, EXERCISE INDUCED 00013 KAISER FOUNDATION SAC-HOSPITAL MENDOZA.GERICKA L 2025 MORSE AVENUE MRN: 110011694288 HOSPITAL DOB: 6/20/1995, Sex: F SACRAMENTO, CA 95825-2115 Adm:3/19/2011. D/C:3/19/2011 ED PROVIDER NOTES (continued) No active medications on file as of 03/19/2011 ALLERGIES: No known allergies History Social History • Marital Status: Single/Never Married Spouse Name: N/A Number of Children: N/A • Years of Education: N/A Occupational History • Not on file. Social History- Main Topics • Tobacco Use: Never • Alcohol Use: Not on file • Drug Use: Not on file • Sexually Active: Not on file other Topics Concern • Not on file Social History Narrative • No narrative on file Review of Systems Constitutional: Negative for fever. HENT: Negative for headaches. Cardiovascular: Negative for chest pain. Respiratory: Is not experiencing shortness of breath. Gastrointestinal: Negative for abdominal pain. Genitourinary; Negative for flank pain. Musculoskeletal; Positive for back pain. Negative for myalgias, neck pain, joint pain and falls. Neurological: Negative for loss of consciousness. Physical Exam Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No distress. BP 108/57 I Pulse 55 | Temp 97.3 "F (36.3 °C) | Resp 17 | Wt 46.267 kg (102 Ib) | Sp02 100% HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. Eyes: Extraocular motions are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Neck: Normal range of motion. Neck supple. No JVD present. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop and no friction rub. 00014 c KAISER FOUNDATION SAC-HOSPITAL MENDOZA.GERICKAL 2025 MORSE AVENUE MRN: 110011694268 HOSPITAL DOB: 6/20/1995, Sex: F SACRAMENTO, CA 95825-2115 Adm:3/19/2011, D/C:3/19/2011 ED PROVIDER NOTES (continued) No murmur h6ard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rales. No seatbelt mark Abdominal: Soft. Bowel sounds are nomial. She exhibits no distension. No tenderness. She has no rebound and no guarding. Musculoskeletal: Normal range of motion. She exhibits no edema. Mild para spinal thoracic back TTP .with no bruising or bony tenderness. Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit. Skin: Skin is warm and dry. No rash noted. ED COURSE: No treatment necessary. MDM: Mild upper back pain 1 day s/p MVA. Given mild sx and normal exam, no need for x-rays as significant injury not suspected. Pt advised of findings and OTC meds and rest advised. Will f/u with PCP prn. IMPRESSlON/PLAN: Dx: PAIN, BACK, (primary encounter diagnosis) Comments: Dx: CAUSE OF INJURY. MVA Comments: The patient's current list of medications was reviewed and reconciled. HERNANDO GARZON MD Eleclronir;.-5ily signed by Garzon. Hernando (M.D.) on 03/19'11 2200 Notes from linked episodes •* None ** Discharge Instructions Mendoza, Gericka L (MR #110011694268) Dale Status User User Type Discharge Note 03/19/11 2139 Pended Garzon, Hernando (M.D.) Physician Original Note: (Do NOT put PATIENT INSTRUCTIONS In this space! Clerical Instructions only.) DC Clerk to do the following: 00015 KAISER PERMAMENTE^LG-BiGHORN MENDOZA.GERICKAL 1 i_ixivir^iM 9201 BIG HORN BLVD MRN: 110011694268 DOB: 6/20/1995, Sex: F ELK GROVE, CA 95758-1240 Enc. Date:04/08/11 Encounter Information (continued ntinued) |.1iDate&!T:imei:::[:;:i::1:::::::i::1.;^ 4/8/2011 4:30 PM MARIA NORMA VIC A. BANEZ MD Elg-Pedl >Big Horn ELGA Visit Notes ARLETTE ARRIAGA WIA Fri Apr 8, 2011 4:38 PM Electronically signed by ARLETTE ARRIAGA MA on Fri Apr 8, 2011 4:38 PM Progress Notes Banez, Maria Norma Vic A. (M.D.) Physician 4/8/11 07:54 PM Signed SUBJECTIVE: Gericka L Mendoza is a 15 Y female who was in a motor vehicle accident 3/18/2011 She was a passenger in the front seat, with shoulder belt, with seat belt. Description of impact: rear-ended. The patient was tossed forwards and backwards during the impact. The patient denies a history of loss of consciousness, head injury, striking chest/abdomen on steering wheel, nor extremities or broken glass in the vehicle. Has complaints of pain at upper back 1 day after the accident, seen in the ED on 3/19/2011. Per ED note, other than mild TENDER TO PALPATION to upper back, patient otherwise normal. Hence no imaging done.