Preview
MC-350
[ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 245190 FOR COURT USE ONLY
INAME: JasonM. Sherman, Esq.
FIRM NAME: Johnson, Schachter & Lewis, a P.L.C.
STREET ADDRESS: 4545 River Park Drive, Suite 204
cry: Sacamento STATE: CA 2IP CODE: 95815 ELECTRONICALLY FILED
TELEPHONENO.: (916) 921-5800 FAX NO. (916) 921-0247 Superior Court of California
EMAIL ADDRESS: jason@jsl-law.com County of Placer
ATTORNEY FOR (Name): Defendant Roseville Joint Union High School District
02/29/2024 at 11:22:06 AM
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Placer By: Breanne E Sanders
STREET ADDRESS: 10820 Justice Center Drive Deputy Clerk
MAILING ADDRESS:
CITY AND ZIP CODE: Roseville, 95678
BRANCH NAME: Hon. HowardG. Gibson Courthouse
ICASE NAME: ‘CASE NUMBER:
Kaylee Fayter, a minor, v. Roseville Joint Union High School District 8-C¥-0052251
HEARING DATE:
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM 04/09/2024
OR ACTION OR DISPOSITION OF PROCEEDS OF DEPT. TIME:
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 42 8:30 AM
NOTICE TO PETITIONER
Except as noted below, you must use this form to request court approval of (1) the compromise of a minor's disputed claim.
(2) the compromise or settlement of a pending action or proceeding to which a minor or a person with a disability (including a
conservatee) is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See
Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.)
Both you and the minor or person with a disability must attend the hearing on this petition unless the court dispenses with a personal
appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and the
presentation of other evidence relating to the claim and the nature and extent of the injury, care, treatment, and hospitalization.
The court has authority to consider a request for expedited approval without a hearing of the compromise of certain claims or actions
or the disposition of the proceeds of certain judgments. To determine whether your claim, action, or judgment qualifies, see Cal. Rules
of Court, rule 7.950.5, If you want to request expedited consideration, you must use form MC-350EX.
1 Petitioner (name or pseudonym’): Kristen Fayter
is the (check all boxes that apply). [EJ Parent [] Guardian ad litem* [] Guardian [] Conservator
[] Other (specify relationship).
of the claimant identified in item 2. (*Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that
pseudonym. (See Code Civ. Proc., § 372.5.)
Claimant (name): Kaylee Fayter, a minor
a. Address: 1392 Cloverdale Circle, Roseville, CA 95661
b. Date of birth: 3/2/2009 c. Age: 14 d. [3] Minor or [] Person with a disability
(If the claimantis an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a
conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.)
e. [__] Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or judgment.
f. [J Does not have a conservator of the estate.
3. Claim The claim of the minor or adult person with a disability (check one):
Js not the subject of a pending action or proceeding. (Complete items 4-23.)
b. [1] |s the subject of a pending action or proceeding that will be compromised or settled without a trial. (Complete items 4-23.)
Name of court:
Case no. Trial date:
c. [__] Is the 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 (excluding interest and costs) of (specify total). $
Defendants (names:
Additional defendants listed on Attachment 3.
The judgment was filed on (date).
(Attach a copy of the (proposed) judgment as Attachment 3c and complete items 12-23.)
Page 1 of 10
Form Adopted for Alternative Mandatory Use Code of Civil Procedure, § 372:
Instead of Form MC-3 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Probate Code, §§ 3500, 3600-3613;
Judicial Council of California OR ACTION OR DISPOSITION OF PROCEEDS OF al, Rules of Court, rules 3.1384,
MC-350 [Rev. January1, 2021] 7.401, 7.950-7.952
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY wsnv.courts.ca.gov
MC-350
CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER:
8-C¥-0052251
Incident or accident The incident or accident occurred as follows:
a. Date: October 9, 2023 Time: 3:40 p.m.
b. Place: Oakmont High School
c. Persons involved (names):
Claimant, a minor
[J Continued on Attachment 4.
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe what happened):
Claimant was as athlete on the volleyball team and was setting up the volleyball pole and the pole "recoiled" and hit her in the face.
[1] Continued on Attachment 5.
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Claimant lost teeth #7 and #8. Number 7 is broken at the gum line and #8 is cracked. Both teeth are dead and require intense
dental treatment/orthodontic treatment. Claimant has needed root canals, retainers, fillings, crowns and at least one dental implant.
[) Continued on Attachment 6.
Treatment
The claimant received the following care and treatment for the injuries described in item 6 (describe):
To date, Claimant has received treatment at Favero Orthodontics for a new retainer and x-rays, a consult at Creekside Endodontist
for root canals and root canals, and Sierra Dental Practice for fillings and treatment. Future treatment will include two (2) crowns,
two (2) implants, and new x-rays after crowns/implants.
[J Continued on Attachment 7.
Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries
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 8. A new report is not necessary if a previous report accurately describes the claimant's current condition.)
a. [__] The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent
injuries.
b. The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms):
Treatment not yet obtained will include two (2) crowns, to (2) implants, and new x-rays after crowns/implants.
[] Continued on Attachment 8b.
c. [__] The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms):
[] Continued on Attachment 8c.
MC-350 (Rev. January 1, 2021) Page
2 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
|CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER:
8-C¥-0052251
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.
10. Amount and terms of settlement
To settle the claim in 3a or 3b, 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): $ 10,305.10
b. The defendants and amounts offered by each are as follows (specify):
efendants (names, Amounts
Roseville Joint Union High School District $ 10,305.10
[_] Defendants and amounts offered continued on Attachment 10b.
The terms of settlement are as follows. (If the settlement is to be paid in installments, both the total amount and the present
value of the settlement must be included.)
The Claimant has agreed to settle this claim for the costs of past and future Dental/Orthodontic bills. The total
settlement includes $3,126.10 to reimburse Claimant's mother for amounts paid for past treatment which were not
covered by insurance. The remaining $7,179.00 is to cover future treatment pursuant to the Treatment Plan from
Sierra Dental Practice, attachment 8, which are not covered by insurance.
[] Continued on Attachment 10c.
11. Settlement payments to others
a. [(_] No defendant named in item 10b 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.
To settle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants
named in item 10b have also offered to pay money to a person or persons other than claimant.
(1) The total amount offered by all defendants to others is (specify): $ 3,126.10
(2) Petitioner [J does not have has acclaim against the recovery of the claimant (other than for
reimbursement of fees or expenses paid by petitioner and listed under item 14).
(If you answered “has,” explain in Attachment 11b(2) the circumstances and the effect your claim has on the proposed
compromise of the claim described in this petition.)
(3) Petitioner is not is a plaintiff in the same action with the claimant.
(If you answered ‘is," explain in Attachment 11b(3) the circumstances and the effect your claim and its disposition has on
the proposed compromise of the claim or action described in this petition.)
(4) [6€] Petitioner would receive money under the proposed settlement.
(5) The settlement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
Kristen Fayer 3,126.10
[) Additional plaintiffs or claimants and amounts are listed on Attachment 41b(5).
(6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named
above are specified in Attachment 1 1b(6).
MC-350 [Rev. January1, 2021) Page
3 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
ICASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High Schoo! District CASE NUMBER:
8-C¥-0052251
12. The claimant's medical expenses—including medical expenses paid by petitioner, Medicare, Medi-Cal, and private
insurers—to be paid or reimbursed from proceeds of settlement or judgment
a. Totals
(1) Total medical expenses before any reductions:
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($
(3) Total of negotiated, contractual, or statutory reductions, if any: ($
(4) Total medical expenses to be paid or reimbursed from the proceeds: 3,126.10
(5) Total amount of statutory or contractual liens, if any:
Medical expenses were paid and are to be reimbursed from the proceeds as follows:
(1) Paid by petitioner in the amount of: $ 3,126.10
(2) Paid by private health insurance or a self-funded plan under:
‘a) [__] An Employee Retirement Income Security Act (ERISA) insured plan.
(b) [-_] An ERISA self-funded plan.
(c) [3] ANon-ERISA insured plan.
(d) [] ANon-ERISA self-funded plan
(e) Amount paid by plan: $ 1,260.90
(f) Amount of reimbursement to the plan from the proceeds of the settlement or judgment:
(i) No reimbursement is requested by the plan.
(ii) (7) Reimbursement is to be made to the plan, and:
(A) [_] There is a contractual reduction of: ($ )
(B) [__] There is a negotiated reduction of: & )
(C) [-_] No reduction has been agreed to,
for a total reimbursement to the plan, in full satisfaction of its lien rights, in the amount of: $
(3) [] Paid by Medicare in the amount of: $
less the statutory reduction in the amount of: gS
for a total reimbursement to Medicare in the amount of.
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 12b(3).)
(4) [1] Paid by Medi-Cal in the amount of: $
(a) [] Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code,
§ 14124.73.) A copy of the notice and proof of delivery:
[1 is attached [) was filed in this case on (date):
(b) [] Notice of this claim or action has not been given to the Director of Health Care Services. (Explain why notice has
not been given in Attachment 12b(4)(b).)
(c) [] 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 12b(4)(c).)
(d) [_] Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and
(check one).
(i) [-] Is filing a motion seeking a reduction of the lien concurrently with this petition.
(ii) [_] Requests that the court reserve jurisdiction over this issue.
The amount of the lien in dispute is: $
(5) (a) (i) [GC There are no statutory or contractual liens for payment of claimant's medical expenses.
(ii) [-] There are one or more statutory or contractual liens of medical service providers for payment of claimant's
medical expenses. The total amount claimed under these liens is: $
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $
(Provide requested information for each lienholder and other specified medical service providers on next page.)
MC-350 [Rev. January 1, 2021) Page
4 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER:
8-CV-0052251
12. Claimant's medical expenses (continued)
b. (6) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or
any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and
the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows:
(i) (A) Provider (name): Creekside Orthodontics
(B) Address: 10 Sierra Gate Plaza , Suite190
Roseville, CA 95678
(C) Amount charged: 3,772.00
(D) Amount paid (whether or not by insurance): Ss 2,551.10)
(E) Negotiated reduction, if any: ($ )
(F) Amount to be paid from proceeds of settlement or judgment: 2,551.10
(ii) (A) Provider (name): Sierra Dental
(B) Address: 9290 Sierra College Blvd. #300
Roseville, CA 95661
(Cc) Amount charged: 269.00
(D) Amount paid (whether or not by insurance): ($ 269.00)
(E) Negotiated reduction, if any: ( )
(F) Amount to be paid from proceeds of settlement or judgment: 269.00
(iil) (A) Provider (name): Favero Orthodontics
(B) Address: 1603 Eureka Rd. Ste. 400
Roseville, CA 95661
(C) Amount charged: $ 346.00
(D) Amount paid (whether or not by insurance): (S 346.00)
(E) Negotiated reduction, if any: ($ )
(F) Amount to be paid from proceeds of settlement or judgment: $ 346.00
[] Continued on Attachment 12b(5). (Provide information about additional providers in the above format, including
providers paid or to be paid by petitioner, for which payment reimbursement is requested in item 12b(1), above.
You may use form MC-350(A-12b(5)) for this purpose.)
13. Claimant's attorney's fees and all other expenses (except for medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment
a. Total amount of attorney's fees for which court approval is requested: $ 0.00
(If fees are requested, attach as Attachment 13a a declaration from the attorney explaining the basis for the request, including a
discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Respond to item 17a(2) on page 7 and attach a
copy of any written attorney fee agreement as Attachment 17a.)
The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment:
Items Payees (names) Amounts
[] Continued on Attachment 13b. Total: $
MC-350 (Rev. January 1, 2024} Page
§ of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
ICASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER:
8-CV¥-0052251
14. Reimbursement of fees and expenses paid by petitioner
a. [__] Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested.
Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's fees and expenses for which
reimbursement is requested.
(1) [-_] Medical expenses listed in item 12: $ 3,126.10
(2) [-] Attorney's fees included in the total fee amount shown in item 13a: $
(3) [] Other expenses included in the total shown in item 13b: $
Total: $ 3,126.10
(Attach proofs of the fees and expenses incurred and the payments made or obligations to pay incurred, e.g., bills or invoices,
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
15. Net balance of proceeds for the claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
after payment of all requested fees and expenses is: 7,179.00
16. Summary
a Gross amount of proceeds of settlement or judgment: 10,305.10
b. Medical expenses to be paid from proceeds of settlement or judgment: 3,126.10
©. Attorney's fees to be paid from proceeds of settlement or judgment: 0.00
d Expenses (other than medical) to be paid from proceeds of settlement
or judgment: 0.00
Total fees and expenses to be paid from proceeds of settlement or
judgment (add (b), (c), and (d)): (S 126.10)
Balance of proceeds of settlement or judgment available for claimant
after payment of all fees and expenses (subtract (e) from (a)): 7,179.00
MC-350 [Rev. January 1, 2021] Page 6 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
‘ASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER:
8-CV¥-0052251
17. Information about attorney representing or assisting petitioner
a. (1) [_] Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with
respect to the claim asserted. (Skip the rest of item 17 and go to item 18.)
(2) [3<] Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim
asserted. Petitioner and the attorney do not [5] do have an agreement for services provided in
connection with the claim giving rise to this petition
(If you answered "do," attach a copy of the agreement as Attachment 17a, and complete items 17b-17f.)
The attorney who has represented or assisted petitioner is (name):
Jason M. Sherman
(1) State Bar number: 245190
(2) Law firm: Johnson, Schachter & Lewis, a P.L.C.
(3) Address:
1545 River Park Dr., Suite 204, Sacramento, CA 95815
(4) Telephone number: (916) 921-5800 (5) Email: jason@jsl-law.com
The attorney has not [-] has received attorney's fees or other compensation in addition to that requested in
this petition for services provided in connection with the claim giving rise to this petition. (/f you answered "has," identify the
person who paid the fees or other compensation, the amounts paid, and the dates of payment):
From whom (names) Amounts Dates
[] Continued on Attachment 17c.
The attorney [__] did not did become concerned with this matter, directly or indirectly, at the instance of a party
against whom the claim is asserted or a party's insurance carrier. (If you answered "did," explain the circumstances in
Attachment 17d.)
The attorney [__] is not De]is representing or employed by any other party or any insurance carrier involved in the
matter. (If you answered ‘is,” identify the party or carrier and explain the relationship in Attachment 17e.)
The attorney [EJ does not [2€] does expect to receive attorney's fees or other compensation in addition to that
requested in this petition for services provided in connection with the claim giving rise to this petition. (if you answered “does,”
identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment):
From whom (names; Amounts Expected date:
Roseville Joint Union High Schoo! District
Continued on Attachment 17f.
MC-350 [Rev. January 1, 2021] Page 7 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High Schoo! District CASE NUMBER:
8-C¥-0052251
18. Disposition of balance for claimant (check eithera or b, then check each option requested and enter amount(s):
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) [_] Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the
guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(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 18a(1) in insured accounts in one or more 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 18a(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 all that apply):
@) C$ 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 18a(3)(a).
) C$ 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 18a(3)(b).
© L$ 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 18a(3)(c).
@) [$8 to be transferred to the trustee of a trust that is either created by or approved in the order
approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of
age and contains all other terms and conditions determined to be necessary by the court to protect the minor's
interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 18a(3)
(d).
[] A copy of the (proposed) judgment is attached as Attachment 3c.
e) C$ to be transferred to the trustee of a special needs trust under Probate Code section 3604
for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust
and the property to be transferred are specified in Attachment 18a(3)(e).
b. There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the
disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested):
(1) [-_] A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed
ant of money or other property be paid or delivered to the person so appointed. The money or
other property are specified in Attachment 18b(1).
2 Cos 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 18b(2).
@) COs 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 18b(3).
4 Cos be paid or transferred to the trustee of a special needs trust established under Probate Code
section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs.
trust and the money or other property to be paid or transferred are specified in Attachment 18b(4).
6) C$ be paid or delivered to a parent of the minor, without bond, on the terms and under the
conditions specified in Probate Code sections 3401-3402. The name and address of the parent and the money or
other property to be delivered are specified in Attachment 18b(5). (Value of minor's entire estate, including the money
or property to be delivered, must not exceed $5,000.)
6) C$ 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 18b(6).
MC-350 {Rev. January 1, 2021) Page
8 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High Schoo! District CASE NUMBER;
8-CV¥-0052251
18. Disposition of balance of proceeds of settlement or judgment (continued)
There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the
disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested):
C$ be transferred to the trustee of a trust that is either created by or approved in the order
approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age,
and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests.
The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7).
[1] A copy of the (proposed) judgment is attached as Attachment 3c.
(8) () $7,179.00 of money be held on any conditions the court determines are in the best interest of the minor
or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not
exceed $20,000.)
9 C$ of property other than 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 and the property are specified in
Attachment 18b(9).
(10) $ 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).
(11) $ be paid or delivered to the adult person with a disability. The money or other property is
specified in Attachment 18b(11).
19.[_] Statutory liens for special needs trust
Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Probate Code
section 3604, if any, will be satisfied):
[) Continued on Attachment 19.
20.[-_] Additional orders
Petitioner requests the following additional orders (specify and explain):
[-) Continued on Attachment 20.
MC-350 [Rev. January 1, 2024} Page
9 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
a tmnt SOLO be a
KEE OY aah 1iua
ae BOERS me a dE 4 et ase
CASE NAME: Kaylee Fayler, a minor, v. Roseville Joint Union MC-350
High School District ‘CASE NUMBER.
8-CV-0052251
21.((] |, the claimant named in item 2, consent to the
order or judgment requested in this petitio
(Required if the claimant is an a dult n.
order or judgment and does not ‘avewitha conse
a disability who has the capacity, under Probate Code
rvator of the estate. (Soe Prob. Code, § 3613,))
section 812, to consent to the
Date:
(TYPE OR PRINT NAME OF CLAIMANT)
(SIGNATURE OF CLAIMANT)
22. Petitioner recommends approval of the
proposed compromise,
reasonable, and in the best interest of t he settlement, , of disposition of judgment proceeds
claimant, Petitioner
disposition and make any other orders that are just and reasonareq juests that the Court approve this compromise,
to the court as fair,
settlement, or
ble.
23. Number of pages attached: g4
Date: February 2(2024
Jason M. Sherman, Esq.
(TYPE OR PRINT NAME OF ATTORNEY) ov (GIGNATURE OFATTORNEY) i
declare under penalty of perju
attachments is true and correct. .
ty under the laws of the State of California that the foregoing informatio
n on this form and all §
Date: FebruaryZe, 2024
Kristen Fayter
(TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER)
MC-350 (Rev January 1, 2021) Page 10 0f 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
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ATTACHMENT 8
. Sierra Dental Practice aE
{ Name Kayleo Foyter
' Birthdato 03/02/2009
| Chart Humbor
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082: TREATMENT
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CASE Trealment Plan
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alt a WAS ie we “ill SF
10/30/2023 D2750 oos2 Crowne Porc WIHigh Noble Metal 975.00 975.00 0.00
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10/30/2023 02984 ops2 Prefabricated Post & Core 197.00 197.00 0.00 }
10/30/2023 02750 ODS2 rown-Pore W/High Noble Metal 175.00 975.00 0.00
10/30/2023 1 8 D2954 ops2 Prefabricated Post & Core 197.00 197.00 0.00
Notes: AFTER ROOT CANAL TREATMENT
Visit 1 Totals: 2344.00 2344.00 0.00 2mp
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11/07/2023 27 D6056 ODS2 Prefab abutment-incl placement
Preview
MC-350 [ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 245190 FOR COURT USE ONLY INAME: JasonM. Sherman, Esq. FIRM NAME: Johnson, Schachter & Lewis, a P.L.C. STREET ADDRESS: 4545 River Park Drive, Suite 204 cry: Sacamento STATE: CA 2IP CODE: 95815 ELECTRONICALLY FILED TELEPHONENO.: (916) 921-5800 FAX NO. (916) 921-0247 Superior Court of California EMAIL ADDRESS: jason@jsl-law.com County of Placer ATTORNEY FOR (Name): Defendant Roseville Joint Union High School District 02/29/2024 at 11:22:06 AM SUPERIOR COURT OF CALIFORNIA, COUNTY OF Placer By: Breanne E Sanders STREET ADDRESS: 10820 Justice Center Drive Deputy Clerk MAILING ADDRESS: CITY AND ZIP CODE: Roseville, 95678 BRANCH NAME: Hon. HowardG. Gibson Courthouse ICASE NAME: ‘CASE NUMBER: Kaylee Fayter, a minor, v. Roseville Joint Union High School District 8-C¥-0052251 HEARING DATE: PETITION FOR APPROVAL OF COMPROMISE OF CLAIM 04/09/2024 OR ACTION OR DISPOSITION OF PROCEEDS OF DEPT. TIME: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 42 8:30 AM NOTICE TO PETITIONER Except as noted below, you must use this form to request court approval of (1) the compromise of a minor's disputed claim. (2) the compromise or settlement of a pending action or proceeding to which a minor or a person with a disability (including a conservatee) is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) Both you and the minor or person with a disability must attend the hearing on this petition unless the court dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and the presentation of other evidence relating to the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court has authority to consider a request for expedited approval without a hearing of the compromise of certain claims or actions or the disposition of the proceeds of certain judgments. To determine whether your claim, action, or judgment qualifies, see Cal. Rules of Court, rule 7.950.5, If you want to request expedited consideration, you must use form MC-350EX. 1 Petitioner (name or pseudonym’): Kristen Fayter is the (check all boxes that apply). [EJ Parent [] Guardian ad litem* [] Guardian [] Conservator [] Other (specify relationship). of the claimant identified in item 2. (*Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ. Proc., § 372.5.) Claimant (name): Kaylee Fayter, a minor a. Address: 1392 Cloverdale Circle, Roseville, CA 95661 b. Date of birth: 3/2/2009 c. Age: 14 d. [3] Minor or [] Person with a disability (If the claimantis an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.) e. [__] Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or judgment. f. [J Does not have a conservator of the estate. 3. Claim The claim of the minor or adult person with a disability (check one): Js not the subject of a pending action or proceeding. (Complete items 4-23.) b. [1] |s the subject of a pending action or proceeding that will be compromised or settled without a trial. (Complete items 4-23.) Name of court: Case no. Trial date: c. [__] Is the 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 (excluding interest and costs) of (specify total). $ Defendants (names: Additional defendants listed on Attachment 3. The judgment was filed on (date). (Attach a copy of the (proposed) judgment as Attachment 3c and complete items 12-23.) Page 1 of 10 Form Adopted for Alternative Mandatory Use Code of Civil Procedure, § 372: Instead of Form MC-3 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Probate Code, §§ 3500, 3600-3613; Judicial Council of California OR ACTION OR DISPOSITION OF PROCEEDS OF al, Rules of Court, rules 3.1384, MC-350 [Rev. January1, 2021] 7.401, 7.950-7.952 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY wsnv.courts.ca.gov MC-350 CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER: 8-C¥-0052251 Incident or accident The incident or accident occurred as follows: a. Date: October 9, 2023 Time: 3:40 p.m. b. Place: Oakmont High School c. Persons involved (names): Claimant, a minor [J Continued on Attachment 4. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened): Claimant was as athlete on the volleyball team and was setting up the volleyball pole and the pole "recoiled" and hit her in the face. [1] Continued on Attachment 5. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Claimant lost teeth #7 and #8. Number 7 is broken at the gum line and #8 is cracked. Both teeth are dead and require intense dental treatment/orthodontic treatment. Claimant has needed root canals, retainers, fillings, crowns and at least one dental implant. [) Continued on Attachment 6. Treatment The claimant received the following care and treatment for the injuries described in item 6 (describe): To date, Claimant has received treatment at Favero Orthodontics for a new retainer and x-rays, a consult at Creekside Endodontist for root canals and root canals, and Sierra Dental Practice for fillings and treatment. Future treatment will include two (2) crowns, two (2) implants, and new x-rays after crowns/implants. [J Continued on Attachment 7. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries 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 8. A new report is not necessary if a previous report accurately describes the claimant's current condition.) a. [__] The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent injuries. b. The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): Treatment not yet obtained will include two (2) crowns, to (2) implants, and new x-rays after crowns/implants. [] Continued on Attachment 8b. c. [__] The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms): [] Continued on Attachment 8c. MC-350 (Rev. January 1, 2021) Page 2 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 |CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER: 8-C¥-0052251 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. 10. Amount and terms of settlement To settle the claim in 3a or 3b, 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): $ 10,305.10 b. The defendants and amounts offered by each are as follows (specify): efendants (names, Amounts Roseville Joint Union High School District $ 10,305.10 [_] Defendants and amounts offered continued on Attachment 10b. The terms of settlement are as follows. (If the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.) The Claimant has agreed to settle this claim for the costs of past and future Dental/Orthodontic bills. The total settlement includes $3,126.10 to reimburse Claimant's mother for amounts paid for past treatment which were not covered by insurance. The remaining $7,179.00 is to cover future treatment pursuant to the Treatment Plan from Sierra Dental Practice, attachment 8, which are not covered by insurance. [] Continued on Attachment 10c. 11. Settlement payments to others a. [(_] No defendant named in item 10b 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. To settle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants named in item 10b have also offered to pay money to a person or persons other than claimant. (1) The total amount offered by all defendants to others is (specify): $ 3,126.10 (2) Petitioner [J does not have has acclaim against the recovery of the claimant (other than for reimbursement of fees or expenses paid by petitioner and listed under item 14). (If you answered “has,” explain in Attachment 11b(2) the circumstances and the effect your claim has on the proposed compromise of the claim described in this petition.) (3) Petitioner is not is a plaintiff in the same action with the claimant. (If you answered ‘is," explain in Attachment 11b(3) the circumstances and the effect your claim and its disposition has on the proposed compromise of the claim or action described in this petition.) (4) [6€] Petitioner would receive money under the proposed settlement. (5) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts Kristen Fayer 3,126.10 [) Additional plaintiffs or claimants and amounts are listed on Attachment 41b(5). (6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified in Attachment 1 1b(6). MC-350 [Rev. January1, 2021) Page 3 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 ICASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High Schoo! District CASE NUMBER: 8-C¥-0052251 12. The claimant's medical expenses—including medical expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—to be paid or reimbursed from proceeds of settlement or judgment a. Totals (1) Total medical expenses before any reductions: (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ (3) Total of negotiated, contractual, or statutory reductions, if any: ($ (4) Total medical expenses to be paid or reimbursed from the proceeds: 3,126.10 (5) Total amount of statutory or contractual liens, if any: Medical expenses were paid and are to be reimbursed from the proceeds as follows: (1) Paid by petitioner in the amount of: $ 3,126.10 (2) Paid by private health insurance or a self-funded plan under: ‘a) [__] An Employee Retirement Income Security Act (ERISA) insured plan. (b) [-_] An ERISA self-funded plan. (c) [3] ANon-ERISA insured plan. (d) [] ANon-ERISA self-funded plan (e) Amount paid by plan: $ 1,260.90 (f) Amount of reimbursement to the plan from the proceeds of the settlement or judgment: (i) No reimbursement is requested by the plan. (ii) (7) Reimbursement is to be made to the plan, and: (A) [_] There is a contractual reduction of: ($ ) (B) [__] There is a negotiated reduction of: & ) (C) [-_] No reduction has been agreed to, for a total reimbursement to the plan, in full satisfaction of its lien rights, in the amount of: $ (3) [] Paid by Medicare in the amount of: $ less the statutory reduction in the amount of: gS for a total reimbursement to Medicare in the amount of. (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 12b(3).) (4) [1] Paid by Medi-Cal in the amount of: $ (a) [] Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.) A copy of the notice and proof of delivery: [1 is attached [) was filed in this case on (date): (b) [] Notice of this claim or action has not been given to the Director of Health Care Services. (Explain why notice has not been given in Attachment 12b(4)(b).) (c) [] 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 12b(4)(c).) (d) [_] Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and (check one). (i) [-] Is filing a motion seeking a reduction of the lien concurrently with this petition. (ii) [_] Requests that the court reserve jurisdiction over this issue. The amount of the lien in dispute is: $ (5) (a) (i) [GC There are no statutory or contractual liens for payment of claimant's medical expenses. (ii) [-] There are one or more statutory or contractual liens of medical service providers for payment of claimant's medical expenses. The total amount claimed under these liens is: $ In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ (Provide requested information for each lienholder and other specified medical service providers on next page.) MC-350 [Rev. January 1, 2021) Page 4 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER: 8-CV-0052251 12. Claimant's medical expenses (continued) b. (6) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows: (i) (A) Provider (name): Creekside Orthodontics (B) Address: 10 Sierra Gate Plaza , Suite190 Roseville, CA 95678 (C) Amount charged: 3,772.00 (D) Amount paid (whether or not by insurance): Ss 2,551.10) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: 2,551.10 (ii) (A) Provider (name): Sierra Dental (B) Address: 9290 Sierra College Blvd. #300 Roseville, CA 95661 (Cc) Amount charged: 269.00 (D) Amount paid (whether or not by insurance): ($ 269.00) (E) Negotiated reduction, if any: ( ) (F) Amount to be paid from proceeds of settlement or judgment: 269.00 (iil) (A) Provider (name): Favero Orthodontics (B) Address: 1603 Eureka Rd. Ste. 400 Roseville, CA 95661 (C) Amount charged: $ 346.00 (D) Amount paid (whether or not by insurance): (S 346.00) (E) Negotiated reduction, if any: ($ ) (F) Amount to be paid from proceeds of settlement or judgment: $ 346.00 [] Continued on Attachment 12b(5). (Provide information about additional providers in the above format, including providers paid or to be paid by petitioner, for which payment reimbursement is requested in item 12b(1), above. You may use form MC-350(A-12b(5)) for this purpose.) 13. Claimant's attorney's fees and all other expenses (except for medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment a. Total amount of attorney's fees for which court approval is requested: $ 0.00 (If fees are requested, attach as Attachment 13a a declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Respond to item 17a(2) on page 7 and attach a copy of any written attorney fee agreement as Attachment 17a.) The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts [] Continued on Attachment 13b. Total: $ MC-350 (Rev. January 1, 2024} Page § of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 ICASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER: 8-CV¥-0052251 14. Reimbursement of fees and expenses paid by petitioner a. [__] Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested. Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's fees and expenses for which reimbursement is requested. (1) [-_] Medical expenses listed in item 12: $ 3,126.10 (2) [-] Attorney's fees included in the total fee amount shown in item 13a: $ (3) [] Other expenses included in the total shown in item 13b: $ Total: $ 3,126.10 (Attach proofs of the fees and expenses incurred and the payments made or obligations to pay incurred, e.g., bills or invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) 15. Net balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment of all requested fees and expenses is: 7,179.00 16. Summary a Gross amount of proceeds of settlement or judgment: 10,305.10 b. Medical expenses to be paid from proceeds of settlement or judgment: 3,126.10 ©. Attorney's fees to be paid from proceeds of settlement or judgment: 0.00 d Expenses (other than medical) to be paid from proceeds of settlement or judgment: 0.00 Total fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): (S 126.10) Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): 7,179.00 MC-350 [Rev. January 1, 2021] Page 6 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 ‘ASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High School District CASE NUMBER: 8-CV¥-0052251 17. Information about attorney representing or assisting petitioner a. (1) [_] Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the claim asserted. (Skip the rest of item 17 and go to item 18.) (2) [3<] Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim asserted. Petitioner and the attorney do not [5] do have an agreement for services provided in connection with the claim giving rise to this petition (If you answered "do," attach a copy of the agreement as Attachment 17a, and complete items 17b-17f.) The attorney who has represented or assisted petitioner is (name): Jason M. Sherman (1) State Bar number: 245190 (2) Law firm: Johnson, Schachter & Lewis, a P.L.C. (3) Address: 1545 River Park Dr., Suite 204, Sacramento, CA 95815 (4) Telephone number: (916) 921-5800 (5) Email: jason@jsl-law.com The attorney has not [-] has received attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition. (/f you answered "has," identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment): From whom (names) Amounts Dates [] Continued on Attachment 17c. The attorney [__] did not did become concerned with this matter, directly or indirectly, at the instance of a party against whom the claim is asserted or a party's insurance carrier. (If you answered "did," explain the circumstances in Attachment 17d.) The attorney [__] is not De]is representing or employed by any other party or any insurance carrier involved in the matter. (If you answered ‘is,” identify the party or carrier and explain the relationship in Attachment 17e.) The attorney [EJ does not [2€] does expect to receive attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition. (if you answered “does,” identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment): From whom (names; Amounts Expected date: Roseville Joint Union High Schoo! District Continued on Attachment 17f. MC-350 [Rev. January 1, 2021] Page 7 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High Schoo! District CASE NUMBER: 8-C¥-0052251 18. Disposition of balance for claimant (check eithera or b, then check each option requested and enter amount(s): 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) [_] Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(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 18a(1) in insured accounts in one or more 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 18a(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 all that apply): @) C$ 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 18a(3)(a). ) C$ 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 18a(3)(b). © L$ 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 18a(3)(c). @) [$8 to be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 18a(3) (d). [] A copy of the (proposed) judgment is attached as Attachment 3c. e) C$ to be transferred to the trustee of a special needs trust under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the property to be transferred are specified in Attachment 18a(3)(e). b. There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (1) [-_] A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed ant of money or other property be paid or delivered to the person so appointed. The money or other property are specified in Attachment 18b(1). 2 Cos 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 18b(2). @) COs 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 18b(3). 4 Cos be paid or transferred to the trustee of a special needs trust established under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs. trust and the money or other property to be paid or transferred are specified in Attachment 18b(4). 6) C$ be paid or delivered to a parent of the minor, without bond, on the terms and under the conditions specified in Probate Code sections 3401-3402. The name and address of the parent and the money or other property to be delivered are specified in Attachment 18b(5). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) 6) C$ 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 18b(6). MC-350 {Rev. January 1, 2021) Page 8 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Kaylee Fayter, a minor, v. Roseville Joint Union High Schoo! District CASE NUMBER; 8-CV¥-0052251 18. Disposition of balance of proceeds of settlement or judgment (continued) There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): C$ be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age, and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7). [1] A copy of the (proposed) judgment is attached as Attachment 3c. (8) () $7,179.00 of money be held on any conditions the court determines are in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not exceed $20,000.) 9 C$ of property other than 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 and the property are specified in Attachment 18b(9). (10) $ 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). (11) $ be paid or delivered to the adult person with a disability. The money or other property is specified in Attachment 18b(11). 19.[_] Statutory liens for special needs trust Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Probate Code section 3604, if any, will be satisfied): [) Continued on Attachment 19. 20.[-_] Additional orders Petitioner requests the following additional orders (specify and explain): [-) Continued on Attachment 20. MC-350 [Rev. January 1, 2024} Page 9 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY a tmnt SOLO be a KEE OY aah 1iua ae BOERS me a dE 4 et ase CASE NAME: Kaylee Fayler, a minor, v. Roseville Joint Union MC-350 High School District ‘CASE NUMBER. 8-CV-0052251 21.((] |, the claimant named in item 2, consent to the order or judgment requested in this petitio (Required if the claimant is an a dult n. order or judgment and does not ‘avewitha conse a disability who has the capacity, under Probate Code rvator of the estate. (Soe Prob. Code, § 3613,)) section 812, to consent to the Date: (TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT) 22. Petitioner recommends approval of the proposed compromise, reasonable, and in the best interest of t he settlement, , of disposition of judgment proceeds claimant, Petitioner disposition and make any other orders that are just and reasonareq juests that the Court approve this compromise, to the court as fair, settlement, or ble. 23. Number of pages attached: g4 Date: February 2(2024 Jason M. Sherman, Esq. (TYPE OR PRINT NAME OF ATTORNEY) ov (GIGNATURE OFATTORNEY) i declare under penalty of perju attachments is true and correct. . ty under the laws of the State of California that the foregoing informatio n on this form and all § Date: FebruaryZe, 2024 Kristen Fayter (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) MC-350 (Rev January 1, 2021) Page 10 0f 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ‘ofyour protection and privacy, ae please /presseS evensthe Cloa ‘button, ina [Print this form | | Save this form | [[Clear this form] ETT ATTACHMENT 8 . Sierra Dental Practice aE { Name Kayleo Foyter ' Birthdato 03/02/2009 | Chart Humbor iL ne ee pene eee - 082: TREATMENT oe CASE Trealment Plan ee alt a WAS ie we “ill SF 10/30/2023 D2750 oos2 Crowne Porc WIHigh Noble Metal 975.00 975.00 0.00 a3 10/30/2023 02984 ops2 Prefabricated Post & Core 197.00 197.00 0.00 } 10/30/2023 02750 ODS2 rown-Pore W/High Noble Metal 175.00 975.00 0.00 10/30/2023 1 8 D2954 ops2 Prefabricated Post & Core 197.00 197.00 0.00 Notes: AFTER ROOT CANAL TREATMENT Visit 1 Totals: 2344.00 2344.00 0.00 2mp Le 11/07/2023 27 D6056 ODS2 Prefab abutment-incl placement