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MC450EX
ATTORNEY OR PARTY NIITHOUT ATTORNEY STATE BAR NUMBER: 309568 FOR COURT USE ONLY
Melvin Marcia
:
FIRM NA E:The Marcia Law Group
sTREET ADDREss: 1 665 $ evil Ia Dr
ciTY: sTATE: CA zIP coDE: 95747
Roseville
TELEPHD "5109103591 FAX Nou
EMAIL ADDREss: melvin(Rmarcialawgrouo.corn
ATTORNEY FOR (Name): Meric Ponoe
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Placer
STR~ETADDREss: 10820 Justice Center Dr
MAILINGADDREss: 1P82P Justice Center Dr
:
Roseville, 95678
BRANCH NAME: $ antucci
CASE NUMBER:
CASE NAME:
Veronica M. Ponce et. al. v. Gina Chalk $ -CV-0049373
AMENDED PETITION FOR EXPEDITED APPROVAL OF
COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF
PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A
~ No hearing date is requested.
HEARING DATE:
DEPT.: TIME:
DISABILITY
NOTICE TO PETITIONER
You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) compromise
of a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a party, or (3) disposition of
the proceeds of a judgment for a minor or person with a disability. ($ ee Code Civ, Proc., tt 372; Prob. Code, H 3500, 3600-3613.) Ycu
may request expedited approval onlyif(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 accurate; and (3) the court does not otherwise order.
If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a
hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise
or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or
Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing.
1.
~
is the (check ail boxes that apply):
Other (specify relationship):
~
Petitioner (name or pseudonym'): Veronica Ponce
Parent ~
Guardian ad litem" ~
Guardian ~
Conservator
of the claimant identified in item 2. ("Petitioner may appear under a pseudonym oniyif appointed as guardian ad litem under that
pseudonym. (See Code Civ. Proc., $ 372.5.))
2. Claimant (name): Mario Ponce
a. Address: 8771 Nicolaus Rd. Lincoln, CA 95648
b. Date of birth: 04/09/2007 c. Age: 16 d. ~v'inor or ~ Person with a disability
(lf the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a
e.
f.
~
conselvator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, g 3613.))
~
Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order.
Does not have a conservator of the estate.
3. Qualification for Expedited Approval
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
(Describ
f.
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.
All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court
~
has made a final determination that all settling parties entered into the settlement in good faith.
g. (1) The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and
(2) ~
12 payable to the claimant and all other persons named in item 12 is in the amount of $ 50,000 or less; or
The settlement described in item 11 represents payment of the 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
investigatio and resultsin
those defendants are judgment-proof outside of their insurance coverage.
Attachment 3.) Page1ofr
Code of 0 vtl Procedure, 6 372;
Instead of Form Mc-350 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Probate Code, I 3500, 3600-361 3;
Cal. Rules of Court, rules 3.139S,
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF 7.101, 7.950, 7.950.5. 7.951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: CASE NUMBER:
Veronica M. Ponce et. ai. v. Gina Chalk S-CV-0049373
4. Claim The claim of the minor or adult person with a disability:
a.
b.
~
~ Is not the subject of a pending action or proceeding. (Complete items 5-23.)
Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.)
Name of court Placer Countv Superior Court
Case no.: S-CV-0049373 Trial date: None
c. ~ Isthe subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the
defendants named below in the amount (exclusive of interest and costs) of (specify): $
~ Additional defendants listed on Attachment 4. ~ The judgment was filed on (date):
(Atfach a copy of the (proposed) judgment as Attachment 4c and complete items 53-23.)
5. Incident or accident The incident or accident occurred as follows:
a. Date: 07/21/2020 Time: 00:42
b. Place: Lincoln, CA
c. Persons involved (names):
Veronica Ponce. Nathan Barellano. and Gina Chalk
~ Additional persons listed on Attachment 5.
6. Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe what happened):
Mario was a passenger in an SUV driven by his mother, Veronica Ponce. A horse owned by Gina Chalk, was allowed to enter
theroadway in the dark, and as a result, caused a collision with the SUV.
~
7. Injuries
Continued on Attachment 6.
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Leg abrasion and chest contusion.
~ Continued on Attachment 7.
8. Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
Mario was examined in the emergency department, including x-rays, to rule out any life-threatening injuries. He did not need any
further medical treatment.
~ Continued on Attachment 8.
page 2 of r
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350 EX
CASE NAME: CASE NUMBER:
Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373
xtento tn)urfesan recovery nongina orap oocopyo any ocorsreportconaininga iagnosiso ecarmantsrn)uncs
or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as
Attachment 9. A new reportis not necessary if a previous report accurately describes the claimant's current condition)
a. ~v'he claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent
b. ~ injuries.
The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are temporary (describe the remaininginjuries and symptoms):
c. ~~ Continued on Attachment 9b.
The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanentinjuries and symptoms):
~ Continued on Attachment 9c.
10. ~ei Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident
or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is
approved by the court and consummated, the claimant will never be able to recover any more compensation from the
settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear.
11. Amount and terms of settlement
To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant:
a. The total amount offered by all defendants named below is (specify): $ 7500.00
b. The defendants and amounts offered by each are as follows (specify):
Defendants names Amoun ts
Gina Chalk $ 7500.00
$
$
~ Additional defendants and amounts offered are listed on Attachment 11b.
$
c. The terms of settlement are described on Attachment 11c. (If the settlementis to be paidin installments, both the total amount
and the present vaiue of the settlement must beincluded)
a. ~
12. Settlement payments to others
No defendant named in item 11b 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. ~v'ne ormore ofthe defendants named in item 11b have also offered to pay moneyto 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.
(2)
(3)
~
(1) The total amount offered by all defendants to others is (specify):
The
Petitioner would receive money under the proposed settlement.
settlement payments are to be apportioned and distributed as follows:
$ 8500.00
Other laintiffs or claimants names Amounts
Nathan Barellano $ 8500.00
$
$
~
$
Additional plaintiffs or claimants and amounts are listed on Attachment 12.
(4) ~ The 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 12.
(5) ~ Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant
named above are specified on Attachment 12.
page 3 of r
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC450EX
CASE NAME: CASE NUMBER:
Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373
13. Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to
be paid or reimbursed from the proceeds of the settlement or judgment
a. Totals
(1) Total medical expenses before any reductions: $ 35590.00
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ 94.32 )
(3) Total of negotiated, contractual, or statutory reductions, if any: ($ 61.31 )
(4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 61.31
(5) Total amount of statutory or contractual liens, any: if $ 61.31
(Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5)
b. (1)
(2)
~
in Attachment 13a.)
~ None of the claimant's medical expenses have been paid by Medicare.
Medicare 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 Medicare demand letter or letter agreement as Attachment 13b(2).)
c. (1) ~ None of the claimant's medical expenses have been paid by Medi-Cal.
(2) ~fr Medi-Cal paid some or all of claimant's medical expenses.
(b)
A copy of the notice and proof of delivery
In full satisfaction of its lien rights,
~
Medi-Cal has agreed to
~
(a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. 8 Inst. Code, II 14124.73,)
is attached
accept
was filed in this matter on (date):
reimbursement
in the amount of: $ 61.31
(Attach a copy of the final Medi-Gal demand letter or letter agreement as Attachment 13c(2).)
d. ~ 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: $
(Attach statements from the plan showing expense payments and requesting reimbursement)
e. ~ Petitioner has paid claimant's medical expenses to be reimbursed in the amount of: $
f. ~
(Seeinstructions foritem 15)
~
(1)
(2)
There are no statutory or contractual liens for payment of the claimant's medical expenses.
There are one or more liens from medical service providers for payment of the claimant's medical expenses.
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $
~
g. (Select (1)
(1)
~v'll
(2)
or (2) below.)
Latest statements from all medical service providers are attached as Attachment 13g.
medical expenses have been paid by private insurance, Medicare, or Medi-Cal.
14. 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
a. Total amount of attorney's fees for which court approval is requested: $ 2485.00
(If fees are requested, attach as Attachment 14a a declaration from the attorney explaining the basis for the request, including a
discussion of applicable factors listedin rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attorney fee
agreementin Attachment 14a.)
b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or
judgment:
Items ~Pa ees names Amounts
Service Processesor and e-filing fees D&T Legal Services $ 235.00
$
$
$
$
$
$
$
~ Continued on Attachment 14b.
Total: $ 235.00
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 14c.
MC-350EX [Rev. January 1, 2021] page 4 of r
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC450EX
CASE NAME: CASE NUMBER:
Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373
15. Reimbursement of fees and expenses paid by petitioner
~v'etitioner has paid none of the fees or expenses listed in items 13 and 14 for which reimbursement is requested.
a.
b. ~~(1)
Petitioner has paid the following total amounts of the claimant's fees and expenses for which reimbursement is requested.
Medical expenses listed in item 13: $ 61.31
~(2) ~dr
(3)
Attorney's fees included in the total fee amount shown in item 14a:
Other expenses included in the total shown in item 14b:
(Attach proofs of the fees and expensesincurred and payments made, e.g., bills orinvoices,
$
$
Total: $
2250.00
235.00
2546.31
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
16. Net balance of proceeds remaining for claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
after payment or reirnbursernent of all requested fees and expenses is (specify): $ 4953.69
17. Summary
a. Gross amount of proceeds of settlement or judgment for claimant: $ 7500.00
b. Medical expenses to be paid from proceeds of settlement or judgment: $ 61.31
c. Attorney's fees to be paid from proceeds of settlement or judgment $ 2250.00
d. Expenses (other than medical) to be paid from proceeds of settlement
or judgment: $ 235.00
e. Total fees and expenses to be paid from proceeds of settlement or
judgment (add (b), (c), and (d)): ($ 2546.31 )
f. Balance of proceeds of settlement or judgment available for claimant
after payment of all fees and expenses (subtract (e) from (a)): $ 4953.69
about attorney representing or assisting petitioner
18. Information
a. The attorney ~ is not ~is representing or employed by another party involved in this matter.
(if you answered "is, eidentify the other party and explain the relationship in Attachment 18a. If the other partyis 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, rule 7.950.5(a)(6).)
b. The attorney ~ has neither received nor expects to receive
other compensation in addition to that requested in this petition for
~services
has received or expects to receive attorney's fees or
provided in connection with the claim giving rise to
this petition (if you answered chas 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):
Amount
From Whom Paid or Ex ected name Date Paid or Ex ected ~Paid or Ex ected
Gina Chalk 5/25/2023 $ 2125.00
$
$
$
$
$
~
$
Continued on Attachment 16b. Total $ 2125 00
page 5 at 7
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: CASE NUMBER:
Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373
Disposition of balance to claimant (check either a or b, then check each option requested and enter amount(s)):
19.
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) Petitionerrequeststhat $ of the proceeds in money or other property be paid or delivered to the
guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is
specified in Attachment 19a(1).
~
(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 19a(1) in one or more insured accounts with financial institutions in this state or with a trust company, subject to
withdrawal only on authorization of the court. The money or other property and the name, branch, and address of
each financial institution or trust company are specified in Attachment 19a(2).
(3) ~ Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship
estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check aii that apply):
(a) ~$ to be deposited in insured accounts in one or more financial institutions in this state,
subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are
specified in Attachment 19a(3)(a).
(b) C3$ to be invested in a single-premium deferred annuity, subject to withdrawal only on
authorization of the court. The terms and conditions of the annuity are specified in Attachment 19a(3)(b).
(c) ~$ to be transferred to a custodian for the benefit of the minor under the California Uniform
Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are
specified in Attachment 19a(3)(c).
b. ~ There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability.
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
(check aii that apply):
~
(1) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed
and $ of money and other property be paid or delivered to the person so appointed. The money
or other property are specified in Attachment 19b(1).
(2) C]$ of money be deposited in insured accounts in one or more financial institutions in this state,
subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are
specified in Attachment 19b(2).
(3) C3 $ of money be invested in a single-premium deferred annuity, subject to withdrawal only on
(4) ~ authorization of the court. The terms and conditions of the annuity are specified in Attachment 19b(3).
$ 4953.69 be paid or delivered to a parent of the minor on the terms and under the conditions specified in
Probate Code sections 3401-3402, without bond. The name and address of the parent and the money or other
property to be delivered are specified in Attachment 19b(4). (Vaiue of minor's entire estate, including the money or
property to be delivered, must not exceed $ 5,000.)
(5) H$ be transferred to a custodian for the benefit of the minor under the California Uniform Transfers
to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred
are specified in Attachment 19b(5).
(6) M$ of money be held on the conditions that the court determines to be in the best interest of the
minor or adult person with a disability. The proposed conditions are specified on Attachment 19b(6). (Value must not
(7) ~ exceed $20,000.)
$ of property other than money be held on the conditions that the courtdeterminesto be in the
best interest of the minor or adult person with a disability. The proposed conditions and the property are specified in
Attachment 19b(7).
(6) CZ$ 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) %$ be paid or transferred to the adult person with a disability. The money or other property is
speciTied in Attachment 19b(9).
Page 6 ef7
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC450EX
CASE NAME: CASENUMSER:
Veronica M. Ponce el. al. v. Gina Chalk S-CV-0049373
20. ~ Additional orders
Petitioner requests the following additional orders (specify and explain):
~ Continued on Attachment 20.
21. ~ I,the claimant named in item 2, consent to the order or judgment requested in this petition.
(Requiredif the claimant is an adult wifh a disability who has the capacity, under Probate Code section 812, to consent to the
order orjudgment and does nol ha ve a conservator of the estate. (See Prob. Code, () 361 3))
Date:
(TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT)
22. Petitioner recommends the proposed compromise, settlement, or disposition of judgment proceeds for the claimant to the court as
being fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise,
settlement, or disposition and make any other orders that are just and reasonable.
23. Number of pages attached: 17
Date: 7/08/2023
Melvin F. Marcia, Esq.
(TYPE OR PRINT NAME) (SIGNAT E OF ATTORNEY)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date: 2023-07-08
Veronica Ponce
(TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER)
Page 7 e(T
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
Minor's compromise for Mario Ponce
Final Audit Report 2023-07-11
Created: 2023-07-1 0
By: Melvin Marcia (metvtnemarctatawgroup.corn)
Status: Signed
Transaction ID: CB JCHBCAABAAO894tkbGQFLWOIWgreunNc83EHD-tay-
"Minor's compromise for Mario Ponce" History
'5 Document created by Melvin Marcia (metvinomarcialawgroup.corn)
2023-07-10- 10:45:41 PM GMT
~+ Document emailed to pro52023@yahoo.corn for signature
2023-07-10- 10:45:49 PM GMT
6 Email viewed by pro52023@yahoo.corn
2023-07-11 - 0:14:11 AM GMT
Oe Signer pro52023@yahoo.corn entered name at signing as Veronica M. Ponce
2023-07-11 - 0:15:00 AM GMT
Fo Document e-signed by Veronica M. Ponce (pro52023@yahoo.corn)
Signature Date: 2023-07-11 - 0:15:02 AM GMT - Time Source: server
0 Agreement completed.
2023-07-11 —
0:15:02 AM GMT
II Adobe Acrobat Sign
ATTACHMENT 9
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CASE NUMBER:
SHORT TITLE: Veronica M. Ponce et. al. v. Gina Chalk
S-CV-0049373
Attachment 12
2 Mr. Nathan Barellano settlement amount was $ 8,500 because he missed a few days of work
3 and was in more pain.
10
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26 (Required for verified pleading) The items on this page stated on information and belief are (specifyitem numbers, not line
numbers):
27
This page may be used with any Judicial Council form or any other paper filed with the court. Page
Form Approved by the ADDITIONAL PAGE
Judicial Council of California Attach to Judicial Council Form or Other Court Paper CRC 201, 801
MC-020 INsw January 1, 1987]
CASE NUMBER
SHORT TITLE: Veronica M. Ponce et. al. v. Gina Chalk
S-CV-0049373
Attachment 13
$ 35,590 was the amount billed by Sutter. $ 94.32 was the amount paid by Medi-Cal. $ 61.31 is the amount
3 acce ted b Medi-Cal as full a 'ment lien amount).
10
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26 (Required for verified pleading) The items on this page stated on information and belief are (specifyitem numbers, not line
numbers):
27
This page may be used with any Judicial Council form or any other paper filed with the court. Page
Form Approved by the
ADDITIONAL PAGE
Judicial Council of California Attach to Judicial Council Form or Other Court Paper CRC 201, 501
MCJt20 [New January 1, 19871
ATTACHMENT 13C (2)
State of California GAVIN NEWSOM, Governor
Department of Health Care Services
Recovery Section, MS 4720
P.O. Box 997425
Sacramento, CA 95899-7425
(916) 445-9891 April 07, 2023
MELVIN MARCIA
ATTORNEY AT LAW
500 14TH ST
OAKLAND, CA
¹94612
900
The Medi-Cal beneficiary listed below has received $ 94.32 in benefits
thxough the Medi-Cal Program related to the third party liability injury
(Injury) on July 21, 2020. The Department of Health Care Services (DHCS)
retains reimbursement rights for the reasonable value of benefits provided
pursuant to Welfare and Institutions Code (W&I Code) sections 14124.70 et
st., and section 14024.
DHCS Case Name MARZO PONCE
DHCS Account Number C97899696E-001
Injury Date July 21, 2020
Amount Due $ 61. 31
DHCS'eimbursement is limited to the lesser of: 1) no more than the
Medi-Cal beneficiary recovers after deducting attorney's fees and
1't'tion
iga xon costs
o paid for by the Medi-Cal beneficiary per W&Z Code
after deducting the director ~Ss reasonable
14]24.78;or 2) the lien amountlitigation
share of attorney's fees W&l and costs pez W&I Code section
124. 72 (d) . Pursuant to
14124.72 Code section 14124. 785 and the information
receive d to datee, DHCS has reduced the lien for reimbursement of the
reasonable value of benefits from $ 94.32 to $ 61.31.
amoun oof $ 61. 31 will satisfy DHCS'ien, subject to
Reimbursement in tth eforth
amount
the conditions set below:
1) Pursuant t W&Z
t to
required to same
Code sections 14124. 785 and 14124. 79, you are
notify DHCS if there are additional settlements arising
out of the Medi-Cal Injury. DHCS retains all statutory lien rights
arising from paid services regarding any other settlemknt,
udgment or award related to the same Injury as authorized by law
2) Zf you are aware of additional services provided as a result of
above-referenced Injury, please notify DHCS immediately. DHCS may
11-1532
MELVIN MARCIA
Page 2
be entitled to additional reimbursement for the reasonable value of
Medi-Cal benefits that were not included in the above-referenced
amount.
3) Payment may become due upon the death of
MARIO PONCE pursuant to WZI Code section
14009.5, as applicable, and/oz tezmination of a trust, if any,
created pursuant to Title 42 U.S. Code 1396(p)(d) (4)(a-c)
for the benefit of MARIO PONCE.
4) If medical payment coverage (MedPay) is available, please notify
this office as this may affect the calculation of reimbursement
due .
Please remit payment in the amount of $ 61. 31. A payment foz less than the
amount owed will be credited to the account but will not be considered
payment in full foz the DHCS lien,
To make an Electronic Funds Transfer (EFT) payment:
1. Go to dhcs. ca. gov/epay.
2. Scroll to" the bottom of the page and select the option "Make an EFT
Payment.
3. On the payment page, you can choose to make a one-time payment or
to apply to become an enrolled user.
To become an enrolled user, complete and submit an enrollment
form found at the bottom of the dhcs.ca.gov/epay webpage.
4. Provide the Medi-Cal beneficiary's DHCS account number and all the
necessary payment, contact, and banking information.
5. Print or save the information on the payment confirmation page,
including the confizmation number, for your records.
EFT is a fast, easy and secure method for payment submission. It offers
many advantages, including free online payment submission, savings on
postage and printing costs, quicker delivery and processing time, and
reduced waste. You have the option to make a one-time payment oz to become
an enrolled user. The enrolled user option allows you to easily make a
payment, schedule future payments, cancel a payment, and track payment
history.
please visit dhcs.ca.gov/epay for more information and to view the EFT
Infozmation Guide with step-by-step instructions for making an EFT payment.
Payment by check or money ordex may take up to 7-10 business days
process and must include the Medi-Cal beneficiary's DHCS account numbez
If you have any questions, please contact the Medi-Cal personal Injury
Program at (916) 445-9891.
Enclosure
11-1533
MELVIN MARCIA
Page 3
CAS3050A (03/21)
PLEASE DETACH AND ENCLOSE WITH YOUR PAYMENT
OR TO MAKE AN EFT PAYMENT, GO TO: DHCS.CA.GOV/SPAY
DHCS Account Number: C97899696E-001
DHCS Case Name : MARIO PONCE
Mail your payment to:
AMOUNT DUE: $ 61.31
Department of Health Care Services
Recovery Branch MS 4720
— AMOUNT ENCI USED: 8
P.O. Box 997421
Sacramento, CA 95899-7421
11-1534
CASE NUMBER:
SHORT TITLE: Veronica M. Ponce et. al. v. Gina Chalk
S-CV-0049373
Attachment 14
$ 2,250 is 30% of the settlement amount. Per the contingency agreement, 30% is the attorney's fee if a
lawsuit is filed. This fee is reasonable as it represents the time and effort put forth by the attorney in
negotiating a settlement offer and preparing a petition for minor's coinpromise. $235 was the cost of
personal service and e-filing through 3rd party vendor.
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16
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20
21
22
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(Rerfuired for verified pleading) The items on this page stated on information and belief are (specifyitem numbers, not line
numbers):
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This page may be used with any Judicial Council form or any other paper filed with the court. Page
Foun Approved Oy fne ADDITIONAL PAGE
Judicial Council of California Attach to Judicial Council Form or Other Court Paper CRC 201, 801
MCJ120 lNow January 1, 198yi
Written Fee Agreement
Contingency Fee Agreement
ATTORNEY-CLIENT FKE AGREEMENT
MELVIN F. MARCIA, Esq. ("Attorney") and VERONICA MARIE POENCE, on behalf of
NATHAN BARELLANO, AND MARIO PONCE, minors (" Clients" ) hereby agree that Attorney
will provide legal services to Clients on the terms set forth below.
1. CONDITIONS
This Agreement will not take effect, and At
Preview
MC450EX ATTORNEY OR PARTY NIITHOUT ATTORNEY STATE BAR NUMBER: 309568 FOR COURT USE ONLY Melvin Marcia : FIRM NA E:The Marcia Law Group sTREET ADDREss: 1 665 $ evil Ia Dr ciTY: sTATE: CA zIP coDE: 95747 Roseville TELEPHD "5109103591 FAX Nou EMAIL ADDREss: melvin(Rmarcialawgrouo.corn ATTORNEY FOR (Name): Meric Ponoe SUPERIOR COURT OF CALIFORNIA, COUNTY OF Placer STR~ETADDREss: 10820 Justice Center Dr MAILINGADDREss: 1P82P Justice Center Dr : Roseville, 95678 BRANCH NAME: $ antucci CASE NUMBER: CASE NAME: Veronica M. Ponce et. al. v. Gina Chalk $ -CV-0049373 AMENDED PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A ~ No hearing date is requested. HEARING DATE: DEPT.: TIME: DISABILITY NOTICE TO PETITIONER You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) compromise of a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a party, or (3) disposition of the proceeds of a judgment for a minor or person with a disability. ($ ee Code Civ, Proc., tt 372; Prob. Code, H 3500, 3600-3613.) Ycu may request expedited approval onlyif(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 accurate; and (3) the court does not otherwise order. If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing. 1. ~ is the (check ail boxes that apply): Other (specify relationship): ~ Petitioner (name or pseudonym'): Veronica Ponce Parent ~ Guardian ad litem" ~ Guardian ~ Conservator of the claimant identified in item 2. ("Petitioner may appear under a pseudonym oniyif appointed as guardian ad litem under that pseudonym. (See Code Civ. Proc., $ 372.5.)) 2. Claimant (name): Mario Ponce a. Address: 8771 Nicolaus Rd. Lincoln, CA 95648 b. Date of birth: 04/09/2007 c. Age: 16 d. ~v'inor or ~ Person with a disability (lf the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a e. f. ~ conselvator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, g 3613.)) ~ Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order. Does not have a conservator of the estate. 3. Qualification for Expedited Approval 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 (Describ f. 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. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court ~ has made a final determination that all settling parties entered into the settlement in good faith. g. (1) The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and (2) ~ 12 payable to the claimant and all other persons named in item 12 is in the amount of $ 50,000 or less; or The settlement described in item 11 represents payment of the 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 investigatio and resultsin those defendants are judgment-proof outside of their insurance coverage. Attachment 3.) Page1ofr Code of 0 vtl Procedure, 6 372; Instead of Form Mc-350 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Probate Code, I 3500, 3600-361 3; Cal. Rules of Court, rules 3.139S, CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF 7.101, 7.950, 7.950.5. 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: CASE NUMBER: Veronica M. Ponce et. ai. v. Gina Chalk S-CV-0049373 4. Claim The claim of the minor or adult person with a disability: a. b. ~ ~ Is not the subject of a pending action or proceeding. (Complete items 5-23.) Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.) Name of court Placer Countv Superior Court Case no.: S-CV-0049373 Trial date: None c. ~ Isthe subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the defendants named below in the amount (exclusive of interest and costs) of (specify): $ ~ Additional defendants listed on Attachment 4. ~ The judgment was filed on (date): (Atfach a copy of the (proposed) judgment as Attachment 4c and complete items 53-23.) 5. Incident or accident The incident or accident occurred as follows: a. Date: 07/21/2020 Time: 00:42 b. Place: Lincoln, CA c. Persons involved (names): Veronica Ponce. Nathan Barellano. and Gina Chalk ~ Additional persons listed on Attachment 5. 6. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened): Mario was a passenger in an SUV driven by his mother, Veronica Ponce. A horse owned by Gina Chalk, was allowed to enter theroadway in the dark, and as a result, caused a collision with the SUV. ~ 7. Injuries Continued on Attachment 6. The following injuries were sustained by the claimant as a result of the incident or accident (describe): Leg abrasion and chest contusion. ~ Continued on Attachment 7. 8. Treatment The claimant received the following care and treatment for the injuries described in item 7 (describe): Mario was examined in the emergency department, including x-rays, to rule out any life-threatening injuries. He did not need any further medical treatment. ~ Continued on Attachment 8. page 2 of r PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 EX CASE NAME: CASE NUMBER: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 xtento tn)urfesan recovery nongina orap oocopyo any ocorsreportconaininga iagnosiso ecarmantsrn)uncs or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 9. A new reportis not necessary if a previous report accurately describes the claimant's current condition) a. ~v'he claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent b. ~ injuries. The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are temporary (describe the remaininginjuries and symptoms): c. ~~ Continued on Attachment 9b. The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanentinjuries and symptoms): ~ Continued on Attachment 9c. 10. ~ei Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is approved by the court and consummated, the claimant will never be able to recover any more compensation from the settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear. 11. Amount and terms of settlement To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant: a. The total amount offered by all defendants named below is (specify): $ 7500.00 b. The defendants and amounts offered by each are as follows (specify): Defendants names Amoun ts Gina Chalk $ 7500.00 $ $ ~ Additional defendants and amounts offered are listed on Attachment 11b. $ c. The terms of settlement are described on Attachment 11c. (If the settlementis to be paidin installments, both the total amount and the present vaiue of the settlement must beincluded) a. ~ 12. Settlement payments to others No defendant named in item 11b 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. ~v'ne ormore ofthe defendants named in item 11b have also offered to pay moneyto 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. (2) (3) ~ (1) The total amount offered by all defendants to others is (specify): The Petitioner would receive money under the proposed settlement. settlement payments are to be apportioned and distributed as follows: $ 8500.00 Other laintiffs or claimants names Amounts Nathan Barellano $ 8500.00 $ $ ~ $ Additional plaintiffs or claimants and amounts are listed on Attachment 12. (4) ~ The 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 12. (5) ~ Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 12. page 3 of r PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC450EX CASE NAME: CASE NUMBER: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 13. Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to be paid or reimbursed from the proceeds of the settlement or judgment a. Totals (1) Total medical expenses before any reductions: $ 35590.00 (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ 94.32 ) (3) Total of negotiated, contractual, or statutory reductions, if any: ($ 61.31 ) (4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 61.31 (5) Total amount of statutory or contractual liens, any: if $ 61.31 (Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5) b. (1) (2) ~ in Attachment 13a.) ~ None of the claimant's medical expenses have been paid by Medicare. Medicare 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 Medicare demand letter or letter agreement as Attachment 13b(2).) c. (1) ~ None of the claimant's medical expenses have been paid by Medi-Cal. (2) ~fr Medi-Cal paid some or all of claimant's medical expenses. (b) A copy of the notice and proof of delivery In full satisfaction of its lien rights, ~ Medi-Cal has agreed to ~ (a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. 8 Inst. Code, II 14124.73,) is attached accept was filed in this matter on (date): reimbursement in the amount of: $ 61.31 (Attach a copy of the final Medi-Gal demand letter or letter agreement as Attachment 13c(2).) d. ~ 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: $ (Attach statements from the plan showing expense payments and requesting reimbursement) e. ~ Petitioner has paid claimant's medical expenses to be reimbursed in the amount of: $ f. ~ (Seeinstructions foritem 15) ~ (1) (2) There are no statutory or contractual liens for payment of the claimant's medical expenses. There are one or more liens from medical service providers for payment of the claimant's medical expenses. In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ ~ g. (Select (1) (1) ~v'll (2) or (2) below.) Latest statements from all medical service providers are attached as Attachment 13g. medical expenses have been paid by private insurance, Medicare, or Medi-Cal. 14. 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 a. Total amount of attorney's fees for which court approval is requested: $ 2485.00 (If fees are requested, attach as Attachment 14a a declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listedin rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attorney fee agreementin Attachment 14a.) b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or judgment: Items ~Pa ees names Amounts Service Processesor and e-filing fees D&T Legal Services $ 235.00 $ $ $ $ $ $ $ ~ Continued on Attachment 14b. Total: $ 235.00 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 14c. MC-350EX [Rev. January 1, 2021] page 4 of r PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC450EX CASE NAME: CASE NUMBER: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 15. Reimbursement of fees and expenses paid by petitioner ~v'etitioner has paid none of the fees or expenses listed in items 13 and 14 for which reimbursement is requested. a. b. ~~(1) Petitioner has paid the following total amounts of the claimant's fees and expenses for which reimbursement is requested. Medical expenses listed in item 13: $ 61.31 ~(2) ~dr (3) Attorney's fees included in the total fee amount shown in item 14a: Other expenses included in the total shown in item 14b: (Attach proofs of the fees and expensesincurred and payments made, e.g., bills orinvoices, $ $ Total: $ 2250.00 235.00 2546.31 canceled checks, credit card statements, explanations of benefits from insurers, etc.) 16. Net balance of proceeds remaining for claimant The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment or reirnbursernent of all requested fees and expenses is (specify): $ 4953.69 17. Summary a. Gross amount of proceeds of settlement or judgment for claimant: $ 7500.00 b. Medical expenses to be paid from proceeds of settlement or judgment: $ 61.31 c. Attorney's fees to be paid from proceeds of settlement or judgment $ 2250.00 d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ 235.00 e. Total fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): ($ 2546.31 ) f. Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): $ 4953.69 about attorney representing or assisting petitioner 18. Information a. The attorney ~ is not ~is representing or employed by another party involved in this matter. (if you answered "is, eidentify the other party and explain the relationship in Attachment 18a. If the other partyis 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, rule 7.950.5(a)(6).) b. The attorney ~ has neither received nor expects to receive other compensation in addition to that requested in this petition for ~services has received or expects to receive attorney's fees or provided in connection with the claim giving rise to this petition (if you answered chas 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): Amount From Whom Paid or Ex ected name Date Paid or Ex ected ~Paid or Ex ected Gina Chalk 5/25/2023 $ 2125.00 $ $ $ $ $ ~ $ Continued on Attachment 16b. Total $ 2125 00 page 5 at 7 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: CASE NUMBER: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 Disposition of balance to claimant (check either a or b, then check each option requested and enter amount(s)): 19. 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) Petitionerrequeststhat $ of the proceeds in money or other property be paid or delivered to the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is specified in Attachment 19a(1). ~ (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 19a(1) in one or more insured accounts with financial institutions in this state or with a trust company, subject to withdrawal only on authorization of the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 19a(2). (3) ~ Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check aii that apply): (a) ~$ to be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 19a(3)(a). (b) C3$ to be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 19a(3)(b). (c) ~$ to be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are specified in Attachment 19a(3)(c). b. ~ There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability. Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check aii that apply): ~ (1) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed and $ of money and other property be paid or delivered to the person so appointed. The money or other property are specified in Attachment 19b(1). (2) C]$ of money be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 19b(2). (3) C3 $ of money be invested in a single-premium deferred annuity, subject to withdrawal only on (4) ~ authorization of the court. The terms and conditions of the annuity are specified in Attachment 19b(3). $ 4953.69 be paid or delivered to a parent of the minor on the terms and under the conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the parent and the money or other property to be delivered are specified in Attachment 19b(4). (Vaiue of minor's entire estate, including the money or property to be delivered, must not exceed $ 5,000.) (5) H$ be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 19b(5). (6) M$ of money be held on the conditions that the court determines to be in the best interest of the minor or adult person with a disability. The proposed conditions are specified on Attachment 19b(6). (Value must not (7) ~ exceed $20,000.) $ of property other than money be held on the conditions that the courtdeterminesto be in the best interest of the minor or adult person with a disability. The proposed conditions and the property are specified in Attachment 19b(7). (6) CZ$ 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) %$ be paid or transferred to the adult person with a disability. The money or other property is speciTied in Attachment 19b(9). Page 6 ef7 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC450EX CASE NAME: CASENUMSER: Veronica M. Ponce el. al. v. Gina Chalk S-CV-0049373 20. ~ Additional orders Petitioner requests the following additional orders (specify and explain): ~ Continued on Attachment 20. 21. ~ I,the claimant named in item 2, consent to the order or judgment requested in this petition. (Requiredif the claimant is an adult wifh a disability who has the capacity, under Probate Code section 812, to consent to the order orjudgment and does nol ha ve a conservator of the estate. (See Prob. Code, () 361 3)) Date: (TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT) 22. Petitioner recommends the proposed compromise, settlement, or disposition of judgment proceeds for the claimant to the court as being fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise, settlement, or disposition and make any other orders that are just and reasonable. 23. Number of pages attached: 17 Date: 7/08/2023 Melvin F. Marcia, Esq. (TYPE OR PRINT NAME) (SIGNAT E OF ATTORNEY) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: 2023-07-08 Veronica Ponce (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) Page 7 e(T PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Minor's compromise for Mario Ponce Final Audit Report 2023-07-11 Created: 2023-07-1 0 By: Melvin Marcia (metvtnemarctatawgroup.corn) Status: Signed Transaction ID: CB JCHBCAABAAO894tkbGQFLWOIWgreunNc83EHD-tay- "Minor's compromise for Mario Ponce" History '5 Document created by Melvin Marcia (metvinomarcialawgroup.corn) 2023-07-10- 10:45:41 PM GMT ~+ Document emailed to pro52023@yahoo.corn for signature 2023-07-10- 10:45:49 PM GMT 6 Email viewed by pro52023@yahoo.corn 2023-07-11 - 0:14:11 AM GMT Oe Signer pro52023@yahoo.corn entered name at signing as Veronica M. Ponce 2023-07-11 - 0:15:00 AM GMT Fo Document e-signed by Veronica M. Ponce (pro52023@yahoo.corn) Signature Date: 2023-07-11 - 0:15:02 AM GMT - Time Source: server 0 Agreement completed. 2023-07-11 — 0:15:02 AM GMT II Adobe Acrobat Sign ATTACHMENT 9 R( ~) ))f:a( .'~ il f 4I'f~)() =-t fi ~ ~ I l ll ~ f ! ,l~ CASE NUMBER: SHORT TITLE: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 Attachment 12 2 Mr. Nathan Barellano settlement amount was $ 8,500 because he missed a few days of work 3 and was in more pain. 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 (Required for verified pleading) The items on this page stated on information and belief are (specifyitem numbers, not line numbers): 27 This page may be used with any Judicial Council form or any other paper filed with the court. Page Form Approved by the ADDITIONAL PAGE Judicial Council of California Attach to Judicial Council Form or Other Court Paper CRC 201, 801 MC-020 INsw January 1, 1987] CASE NUMBER SHORT TITLE: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 Attachment 13 $ 35,590 was the amount billed by Sutter. $ 94.32 was the amount paid by Medi-Cal. $ 61.31 is the amount 3 acce ted b Medi-Cal as full a 'ment lien amount). 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 (Required for verified pleading) The items on this page stated on information and belief are (specifyitem numbers, not line numbers): 27 This page may be used with any Judicial Council form or any other paper filed with the court. Page Form Approved by the ADDITIONAL PAGE Judicial Council of California Attach to Judicial Council Form or Other Court Paper CRC 201, 501 MCJt20 [New January 1, 19871 ATTACHMENT 13C (2) State of California GAVIN NEWSOM, Governor Department of Health Care Services Recovery Section, MS 4720 P.O. Box 997425 Sacramento, CA 95899-7425 (916) 445-9891 April 07, 2023 MELVIN MARCIA ATTORNEY AT LAW 500 14TH ST OAKLAND, CA ¹94612 900 The Medi-Cal beneficiary listed below has received $ 94.32 in benefits thxough the Medi-Cal Program related to the third party liability injury (Injury) on July 21, 2020. The Department of Health Care Services (DHCS) retains reimbursement rights for the reasonable value of benefits provided pursuant to Welfare and Institutions Code (W&I Code) sections 14124.70 et st., and section 14024. DHCS Case Name MARZO PONCE DHCS Account Number C97899696E-001 Injury Date July 21, 2020 Amount Due $ 61. 31 DHCS'eimbursement is limited to the lesser of: 1) no more than the Medi-Cal beneficiary recovers after deducting attorney's fees and 1't'tion iga xon costs o paid for by the Medi-Cal beneficiary per W&Z Code after deducting the director ~Ss reasonable 14]24.78;or 2) the lien amountlitigation share of attorney's fees W&l and costs pez W&I Code section 124. 72 (d) . Pursuant to 14124.72 Code section 14124. 785 and the information receive d to datee, DHCS has reduced the lien for reimbursement of the reasonable value of benefits from $ 94.32 to $ 61.31. amoun oof $ 61. 31 will satisfy DHCS'ien, subject to Reimbursement in tth eforth amount the conditions set below: 1) Pursuant t W&Z t to required to same Code sections 14124. 785 and 14124. 79, you are notify DHCS if there are additional settlements arising out of the Medi-Cal Injury. DHCS retains all statutory lien rights arising from paid services regarding any other settlemknt, udgment or award related to the same Injury as authorized by law 2) Zf you are aware of additional services provided as a result of above-referenced Injury, please notify DHCS immediately. DHCS may 11-1532 MELVIN MARCIA Page 2 be entitled to additional reimbursement for the reasonable value of Medi-Cal benefits that were not included in the above-referenced amount. 3) Payment may become due upon the death of MARIO PONCE pursuant to WZI Code section 14009.5, as applicable, and/oz tezmination of a trust, if any, created pursuant to Title 42 U.S. Code 1396(p)(d) (4)(a-c) for the benefit of MARIO PONCE. 4) If medical payment coverage (MedPay) is available, please notify this office as this may affect the calculation of reimbursement due . Please remit payment in the amount of $ 61. 31. A payment foz less than the amount owed will be credited to the account but will not be considered payment in full foz the DHCS lien, To make an Electronic Funds Transfer (EFT) payment: 1. Go to dhcs. ca. gov/epay. 2. Scroll to" the bottom of the page and select the option "Make an EFT Payment. 3. On the payment page, you can choose to make a one-time payment or to apply to become an enrolled user. To become an enrolled user, complete and submit an enrollment form found at the bottom of the dhcs.ca.gov/epay webpage. 4. Provide the Medi-Cal beneficiary's DHCS account number and all the necessary payment, contact, and banking information. 5. Print or save the information on the payment confirmation page, including the confizmation number, for your records. EFT is a fast, easy and secure method for payment submission. It offers many advantages, including free online payment submission, savings on postage and printing costs, quicker delivery and processing time, and reduced waste. You have the option to make a one-time payment oz to become an enrolled user. The enrolled user option allows you to easily make a payment, schedule future payments, cancel a payment, and track payment history. please visit dhcs.ca.gov/epay for more information and to view the EFT Infozmation Guide with step-by-step instructions for making an EFT payment. Payment by check or money ordex may take up to 7-10 business days process and must include the Medi-Cal beneficiary's DHCS account numbez If you have any questions, please contact the Medi-Cal personal Injury Program at (916) 445-9891. Enclosure 11-1533 MELVIN MARCIA Page 3 CAS3050A (03/21) PLEASE DETACH AND ENCLOSE WITH YOUR PAYMENT OR TO MAKE AN EFT PAYMENT, GO TO: DHCS.CA.GOV/SPAY DHCS Account Number: C97899696E-001 DHCS Case Name : MARIO PONCE Mail your payment to: AMOUNT DUE: $ 61.31 Department of Health Care Services Recovery Branch MS 4720 — AMOUNT ENCI USED: 8 P.O. Box 997421 Sacramento, CA 95899-7421 11-1534 CASE NUMBER: SHORT TITLE: Veronica M. Ponce et. al. v. Gina Chalk S-CV-0049373 Attachment 14 $ 2,250 is 30% of the settlement amount. Per the contingency agreement, 30% is the attorney's fee if a lawsuit is filed. This fee is reasonable as it represents the time and effort put forth by the attorney in negotiating a settlement offer and preparing a petition for minor's coinpromise. $235 was the cost of personal service and e-filing through 3rd party vendor. 12 14 15 16 17 18 19 20 21 22 23 24 25 (Rerfuired for verified pleading) The items on this page stated on information and belief are (specifyitem numbers, not line numbers): 27 This page may be used with any Judicial Council form or any other paper filed with the court. Page Foun Approved Oy fne ADDITIONAL PAGE Judicial Council of California Attach to Judicial Council Form or Other Court Paper CRC 201, 801 MCJ120 lNow January 1, 198yi Written Fee Agreement Contingency Fee Agreement ATTORNEY-CLIENT FKE AGREEMENT MELVIN F. MARCIA, Esq. ("Attorney") and VERONICA MARIE POENCE, on behalf of NATHAN BARELLANO, AND MARIO PONCE, minors (" Clients" ) hereby agree that Attorney will provide legal services to Clients on the terms set forth below. 1. CONDITIONS This Agreement will not take effect, and At