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MC-351
ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 332732 FOR COURT USE ONLY
NAME: George Chryssafis, Esq.
FIRMNAME: CLAYEO C. ARNOLD, PLC
STREET ADDRESS: 865 Howe Avenue
CITY: Sacramento STATE: CA ZIP CODE: 95825
TELEPHONE NO.: 91 6_777_7777 FAX NO.: 91 6_924_1 829
EMAIL ADDRESS: gchryssafis@justicedyou.com
ATTORNEY FOR (Name): Plaintiff, Keyana Barber as GAL for Jeyana Grant & Jovoni Halstead
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento
STREET ADDRESS: 720 Nmth Street
MAILING ADDRESS: 720 Ninth Street
CITY AND ZIP CODE: Gacramento, CA 95814
BRANCH NAME: Cjvil Division
CASE NAME:
Jovoni Halstead & Jeyana Grant v. Venita Commer, et al.
CASE NUMBER:
ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Z/LICV 00 Lfl ]7
OR DISPOSITION OF PROCEEDS OF JUDGMENT HEARING DATE, IF ANY: DEPT.:
FOR MINOR OR PERSON WITH A DISABILITY
1. Hearing
a. x']
[ No hearing was held. The matter is eligible for expedited approval under rule 7.950.5 of the California Rules of Court.
b. [_] A hearing was held: Date: Time: Dept.:
c. Judicial officer:
2. Petitioner (name or pseudonym®*): Keyana Barber
is the (check all relationships or representative capacities that apply): [x7] parent [x] guardian ad litem*
[] guardian [_] conservator [__| other (specify):
of the claimant named in item 3. Petitioner has requested approval of the compromise or settlement of a disputed claim or pending
action or the disposition of the proceeds of a judgment for a minor or a person with a disability.
(*Petitioner was appointed guardian ad litem under a pseudonym. (See Code Civ. Proc., § 372.5.))
3. Claimant (name): Jeyana Grant
a. [x] is a minor.
b. [] is a "person with a disability" within the meaning of Probate Code section 3603 who is:
(1) [_] An adult. Claimant's date of birth is (specify):
(2) [_] A minor described in Probate Code section 3603(b)(3).
4. Defendant
The claim or action to be compromised or settled is asserted, or the judgment is entered, against (name of settling or judgment
defendant or defendants (the "payer")):
Venita Commer & David Commer
THE COURT FINDS
5. [_] Notice has been given as required by law.
6. a. [__] The claimant is an adult who has the capacity to consent to this order within the meaning of Probate Code section 812 and
does not have a conservator of the estate. The claimant has given express consent to this order.
b. [_] The claimant's consent to this order is not required because the claimant is a minor, a conservatee, or a person who lacks
the capacity to consent to the order within the meaning of Probate Code section 812.
Page 1 0of 4
DER APPROVING COMPROMISE OF CLAIM OR ACTION MRty
g i Al
2\ OR DISPOSITION OF PROCEEDS OF JUDGMENT ek Hibmof Coie TG Yo, 7053
rm| FORMINOR OR PERSON WITH A DISABILITY
MC-351
CASE NAME: Jovoni Halstead & Jeyana Grant v. VVenita Commer, et al. CASE NUMBER:
THE COURT ORDERS
6. The petition is granted and the proposed compromise or settlement, or the proposed disposition of the proceeds of the judgment, is
approved. The gross amount or value of the settlement or judgment in favor of claimant is: $ 150,000.00.
7. [] Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under Welfare
and Institutions Code section 14124.76. The amount shown payable to the Department of Health Care Services in item 8a(4)
of this order is the full amount of the lien claimed by the department but is subject to reduction on further order of the court
upon determination of the claim for reduction.
8. The payer must disburse the proceeds of the settlement or judgment approved by this order in the following manner:
a. Payment of fees and expenses
Fees and expenses shall be paid by one or more checks or drafts drawn payable to the order of the petitioner and the
petitioner's attorney, if any, or directly to third parties entitled to receive payment identified in this order for the following items of
expense or damage, which are hereby authorized to be paid out of the proceeds of the settlement or judgment:
(1) [X] Attorney's fees in the total amount of: $ 37,500.00 payable to (specify):
CLAYEO C. ARNOLD, PLC
(2) [_] Reimbursement for medical and all other expenses paid by the petitioner or the petitioner's
attorney in the total amount of: $
(3) [_] Medical, hospital, ambulance, nursing, and other similar expenses payable directly to
providers as follows, in the total amount of: $
(a) Payee (name):
(i) address:
(i) Amount: $
(b) Payee (name):
(i) address:
(i) Amount: $
[] Continued on Attachment 8a(3). (Provide information about additional payees in the above format.)
(4) [ Other authorized disbursements payable directly to third parties in the total amount of: $
(Describe and state the amount of each item and provide the name and address of each payee):
[] Continued on Attachment 8a(4).
(5) [X] Total allowance for fees and expenses from the settlement or judgment: 3 37,500.00
uesbTinmLamney fae ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Page 2 of 4
OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY
MC-351
CASE NAME: Jovoni Halstead & Jeyana Grant v. Venita Commer, et al. CASE NUMBER:
8. b. Balance for claimant
The balance of the settlement or judgment available for claimant after payment of all allowed
fees and expenses is: $ 112,500.00
The balance shall be disbursed as follows:
(1) [_] By one or more checks or drafts in the total amount of (specify): $
drawn payable to the order of the petitioner in the petitioner's representative capacity. Each check or draft must bear
an endorsement on the face or reverse that it is for deposit in one or more interest-bearing, federally insured accounts
in the name of the petitioner in the petitioner's representative capacity. No withdrawals may be made from these
accounts ("blocked accounts") except as provided in the Order to Deposit Funds in Blocked Account (form MC-355)
signed at the same time as this order.
(2) [X7] By the following method(s) (describe each method, including the amount to be disbursed by each):
The sum of $112,500.00 shall be paid to MetLife Assignment Company, Inc. (“Assignee”) for the purchase of an
annuity policy from Metropolitan Tower Life Insurance Company (“Annuity Issuer”) to provide future periodic
payments.
[x] Continued on Attachment 8b(2).
(3) [] If money is to be paid to a special needs trust under Probate Code section 3604, all statutory liens in favor of the state
Department of Health Care Services, the state Department of State Hospitals, the state Department of Developmental
Services, and any city and county in California must first be satisfied by the following method
(specify):
[ Continued on Attachment 8b(3).
9. [_] Further orders of the court concerning blocked accounts
The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked account
under item 8b(1):
a. Within 48 hours of receipt of a check or draft described in item 8b(1), the petitioner and the petitioner's attorney, if any, must
deposit the check or draft in the name of petitioner in the petitioner's representative capacity in one or more blocked accounts at
(specify name, branch, and address of each depository, and the amount of each account):
[] Continued on Attachment 9a.
MC-351 [Rev. January 1, 2021]
ORDER APPROVING COMPROMISE OF CLAIM OR ACTION EESES
OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY
MC-351
CASE NAME: Jovoni Halstead & Jeyana Grant v. Venita Commer, et al. CASE NUMBER:
9. b. The petitioner and the petitioner's attorney, if any, must deliver to each depository at the time of deposit three copies of the
Order to Deposit Funds in Blocked Account (form MC-355), which is signed at the same time as this order, and three copies of
the Acknowledgment of Receipt of Order and Funds for Deposit in Blocked Account (form MC-356). The petitioner or the
petitioner's attorney must file a copy of the receipt with this court within 15 days of the deposit. The sole responsibilities of the
petitioner and the petitioner's attorney, if any, are to place the balance in a blocked account or accounts and to file a copy of the
receipt on time.
c. The balance of the proceeds of the settlement or judgment deposited in a blocked account or accounts under item 8b(1) may be
withdrawn only as follows (check (1) or (2)):
(1) [_] No withdrawals of principal or interest may be made from the blocked account or accounts without a further written
order under this case name and number, signed by a judicial officer, and file-stamped by this court. The money on
deposit is not subject to escheat.
(2) [X] The blocked account or accounts belong to a minor, who was born on (date): 11/11/2011
No withdrawals of principal or interest may be made from the blocked account or accounts without a further written
order under this case name and number, signed by a judicial officer, and file-stamped by this court, until the minor
reaches 18 years of age. When the minor reaches 18 years of age, the depaository, without further order of this court,
is authorized and directed to pay by check or draft directly to the former minor, on proper demand, all funds, including
interest, deposited under this order. The money on deposit is not subject to escheat.
10.[[x_] Authorization to execute settlement documents
The petitioner is authorized to execute settlement documents as follows (check only one):
a. [__] On receipt of the full amount of the settlement sum approved by this order and the deposit of funds, the petitioner is
authorized and directed to execute and deliver to the payer (1) a full, complete, and final release and discharge of any and
all claims and demands of the claimant by reason of the accident or incident described in the petition and the resultant
injuries to the claimant and (2) a properly executed dismissal with prejudice.
b. [X] The petitioner is authorized and directed to execute any and all documents reasonably necessary to carry out the terms of
the settlement.
c. [_] The petitioner is authorized and directed to (specify):
[ Continued on Attachment 10c.
11.Bondis [__] ordered and fixed in the amount of: $ [] not required.
12. A copy of this order must be served on the payer immediately.
13.[_] Additional orders
The court makes the following additional orders (specify):
[] Continued on Attachment 13.
Date:
JUDICIAL OFFICER
|:] SIGNATURE FOLLOWS LAST ATTACHMENT
MC-351 [Rev. January 1, 2021] ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Pegedots
OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY
Case Name: Case Number:
Jovoni Halstead & Jeyana Grant v. Venita Commer, et al.
Attachment 8(b)(2) to the
Order Approving the Minor’s Compromise
By way of settlement, Defendant has offered to pay the following sums to the minor Claimants:
Future periodic payments to Jeyana Grant on the dates and in the amounts indicated hereafter
(the “Periodic Payments™):
Payable to Jeyana Grant (“Payee™)
$30,000.00 guaranteed lump sum payable at age 18 (on November 11, 2029).
$40,000.00 guaranteed lump sum payable at age 21 (on November 11, 2032).
$50,000.00 guaranteed lump sum payable at age 24 (on November 11, 2035).
$60,015.92 guaranteed lump sum payable at age 27 (on November 11, 2038).
All sums set forth herein constitute damages on account of personal, physical injuries or sickness,
within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended.
Payee acknowledges that the Periodic Payments cannot be accelerated, deferred, increased, or
decreased by the Payee; nor shall the Payee have the power to sell, mortgage, encumber, or
anticipate the Periodic Payments or any part thereof, by way of assignment or otherwise.
In the event Minor Claimants pre-decease issuance of any of the above payments, Minor
Claimants’ estate shall be designated as Beneficiary and all remaining payments shall be made to
Minor Claimants’ estate. After the age of majority, Minor Claimants may submit a change of
beneficiary in writing to the Assignee. The designation must be in a form acceptable to the
Assignee.
Assignment: The Defendant’s obligation to make the periodic payments described herein shall
be assigned to MetLife Assignment Company, Inc. through a Qualified Assignment and funded
by an annuity contract issued by Metropolitan Tower Life Insurance Company rated A+ by A.M.
Best. To fund the periodic payments, the Defendant will issue a check in the amount of
$112,500.00 payable to MetLife Assignment Company, Inc. and execute the Qualified
Assignment and Release Agreement.
ALL PAYMENTS WILL BE PAID ON THE ABOVE DUE DATES
TO JEYANA GRANT WITHOUT FURTHER AUTHORIZATION FROM
THE COURT.
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MC-351 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 332732 FOR COURT USE ONLY NAME: George Chryssafis, Esq. FIRMNAME: CLAYEO C. ARNOLD, PLC STREET ADDRESS: 865 Howe Avenue CITY: Sacramento STATE: CA ZIP CODE: 95825 TELEPHONE NO.: 91 6_777_7777 FAX NO.: 91 6_924_1 829 EMAIL ADDRESS: gchryssafis@justicedyou.com ATTORNEY FOR (Name): Plaintiff, Keyana Barber as GAL for Jeyana Grant & Jovoni Halstead SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento STREET ADDRESS: 720 Nmth Street MAILING ADDRESS: 720 Ninth Street CITY AND ZIP CODE: Gacramento, CA 95814 BRANCH NAME: Cjvil Division CASE NAME: Jovoni Halstead & Jeyana Grant v. Venita Commer, et al. CASE NUMBER: ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Z/LICV 00 Lfl ]7 OR DISPOSITION OF PROCEEDS OF JUDGMENT HEARING DATE, IF ANY: DEPT.: FOR MINOR OR PERSON WITH A DISABILITY 1. Hearing a. x'] [ No hearing was held. The matter is eligible for expedited approval under rule 7.950.5 of the California Rules of Court. b. [_] A hearing was held: Date: Time: Dept.: c. Judicial officer: 2. Petitioner (name or pseudonym®*): Keyana Barber is the (check all relationships or representative capacities that apply): [x7] parent [x] guardian ad litem* [] guardian [_] conservator [__| other (specify): of the claimant named in item 3. Petitioner has requested approval of the compromise or settlement of a disputed claim or pending action or the disposition of the proceeds of a judgment for a minor or a person with a disability. (*Petitioner was appointed guardian ad litem under a pseudonym. (See Code Civ. Proc., § 372.5.)) 3. Claimant (name): Jeyana Grant a. [x] is a minor. b. [] is a "person with a disability" within the meaning of Probate Code section 3603 who is: (1) [_] An adult. Claimant's date of birth is (specify): (2) [_] A minor described in Probate Code section 3603(b)(3). 4. Defendant The claim or action to be compromised or settled is asserted, or the judgment is entered, against (name of settling or judgment defendant or defendants (the "payer")): Venita Commer & David Commer THE COURT FINDS 5. [_] Notice has been given as required by law. 6. a. [__] The claimant is an adult who has the capacity to consent to this order within the meaning of Probate Code section 812 and does not have a conservator of the estate. The claimant has given express consent to this order. b. [_] The claimant's consent to this order is not required because the claimant is a minor, a conservatee, or a person who lacks the capacity to consent to the order within the meaning of Probate Code section 812. Page 1 0of 4 DER APPROVING COMPROMISE OF CLAIM OR ACTION MRty g i Al 2\ OR DISPOSITION OF PROCEEDS OF JUDGMENT ek Hibmof Coie TG Yo, 7053 rm| FORMINOR OR PERSON WITH A DISABILITY MC-351 CASE NAME: Jovoni Halstead & Jeyana Grant v. VVenita Commer, et al. CASE NUMBER: THE COURT ORDERS 6. The petition is granted and the proposed compromise or settlement, or the proposed disposition of the proceeds of the judgment, is approved. The gross amount or value of the settlement or judgment in favor of claimant is: $ 150,000.00. 7. [] Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under Welfare and Institutions Code section 14124.76. The amount shown payable to the Department of Health Care Services in item 8a(4) of this order is the full amount of the lien claimed by the department but is subject to reduction on further order of the court upon determination of the claim for reduction. 8. The payer must disburse the proceeds of the settlement or judgment approved by this order in the following manner: a. Payment of fees and expenses Fees and expenses shall be paid by one or more checks or drafts drawn payable to the order of the petitioner and the petitioner's attorney, if any, or directly to third parties entitled to receive payment identified in this order for the following items of expense or damage, which are hereby authorized to be paid out of the proceeds of the settlement or judgment: (1) [X] Attorney's fees in the total amount of: $ 37,500.00 payable to (specify): CLAYEO C. ARNOLD, PLC (2) [_] Reimbursement for medical and all other expenses paid by the petitioner or the petitioner's attorney in the total amount of: $ (3) [_] Medical, hospital, ambulance, nursing, and other similar expenses payable directly to providers as follows, in the total amount of: $ (a) Payee (name): (i) address: (i) Amount: $ (b) Payee (name): (i) address: (i) Amount: $ [] Continued on Attachment 8a(3). (Provide information about additional payees in the above format.) (4) [ Other authorized disbursements payable directly to third parties in the total amount of: $ (Describe and state the amount of each item and provide the name and address of each payee): [] Continued on Attachment 8a(4). (5) [X] Total allowance for fees and expenses from the settlement or judgment: 3 37,500.00 uesbTinmLamney fae ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Page 2 of 4 OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-351 CASE NAME: Jovoni Halstead & Jeyana Grant v. Venita Commer, et al. CASE NUMBER: 8. b. Balance for claimant The balance of the settlement or judgment available for claimant after payment of all allowed fees and expenses is: $ 112,500.00 The balance shall be disbursed as follows: (1) [_] By one or more checks or drafts in the total amount of (specify): $ drawn payable to the order of the petitioner in the petitioner's representative capacity. Each check or draft must bear an endorsement on the face or reverse that it is for deposit in one or more interest-bearing, federally insured accounts in the name of the petitioner in the petitioner's representative capacity. No withdrawals may be made from these accounts ("blocked accounts") except as provided in the Order to Deposit Funds in Blocked Account (form MC-355) signed at the same time as this order. (2) [X7] By the following method(s) (describe each method, including the amount to be disbursed by each): The sum of $112,500.00 shall be paid to MetLife Assignment Company, Inc. (“Assignee”) for the purchase of an annuity policy from Metropolitan Tower Life Insurance Company (“Annuity Issuer”) to provide future periodic payments. [x] Continued on Attachment 8b(2). (3) [] If money is to be paid to a special needs trust under Probate Code section 3604, all statutory liens in favor of the state Department of Health Care Services, the state Department of State Hospitals, the state Department of Developmental Services, and any city and county in California must first be satisfied by the following method (specify): [ Continued on Attachment 8b(3). 9. [_] Further orders of the court concerning blocked accounts The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked account under item 8b(1): a. Within 48 hours of receipt of a check or draft described in item 8b(1), the petitioner and the petitioner's attorney, if any, must deposit the check or draft in the name of petitioner in the petitioner's representative capacity in one or more blocked accounts at (specify name, branch, and address of each depository, and the amount of each account): [] Continued on Attachment 9a. MC-351 [Rev. January 1, 2021] ORDER APPROVING COMPROMISE OF CLAIM OR ACTION EESES OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-351 CASE NAME: Jovoni Halstead & Jeyana Grant v. Venita Commer, et al. CASE NUMBER: 9. b. The petitioner and the petitioner's attorney, if any, must deliver to each depository at the time of deposit three copies of the Order to Deposit Funds in Blocked Account (form MC-355), which is signed at the same time as this order, and three copies of the Acknowledgment of Receipt of Order and Funds for Deposit in Blocked Account (form MC-356). The petitioner or the petitioner's attorney must file a copy of the receipt with this court within 15 days of the deposit. The sole responsibilities of the petitioner and the petitioner's attorney, if any, are to place the balance in a blocked account or accounts and to file a copy of the receipt on time. c. The balance of the proceeds of the settlement or judgment deposited in a blocked account or accounts under item 8b(1) may be withdrawn only as follows (check (1) or (2)): (1) [_] No withdrawals of principal or interest may be made from the blocked account or accounts without a further written order under this case name and number, signed by a judicial officer, and file-stamped by this court. The money on deposit is not subject to escheat. (2) [X] The blocked account or accounts belong to a minor, who was born on (date): 11/11/2011 No withdrawals of principal or interest may be made from the blocked account or accounts without a further written order under this case name and number, signed by a judicial officer, and file-stamped by this court, until the minor reaches 18 years of age. When the minor reaches 18 years of age, the depaository, without further order of this court, is authorized and directed to pay by check or draft directly to the former minor, on proper demand, all funds, including interest, deposited under this order. The money on deposit is not subject to escheat. 10.[[x_] Authorization to execute settlement documents The petitioner is authorized to execute settlement documents as follows (check only one): a. [__] On receipt of the full amount of the settlement sum approved by this order and the deposit of funds, the petitioner is authorized and directed to execute and deliver to the payer (1) a full, complete, and final release and discharge of any and all claims and demands of the claimant by reason of the accident or incident described in the petition and the resultant injuries to the claimant and (2) a properly executed dismissal with prejudice. b. [X] The petitioner is authorized and directed to execute any and all documents reasonably necessary to carry out the terms of the settlement. c. [_] The petitioner is authorized and directed to (specify): [ Continued on Attachment 10c. 11.Bondis [__] ordered and fixed in the amount of: $ [] not required. 12. A copy of this order must be served on the payer immediately. 13.[_] Additional orders The court makes the following additional orders (specify): [] Continued on Attachment 13. Date: JUDICIAL OFFICER |:] SIGNATURE FOLLOWS LAST ATTACHMENT MC-351 [Rev. January 1, 2021] ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Pegedots OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Case Name: Case Number: Jovoni Halstead & Jeyana Grant v. Venita Commer, et al. Attachment 8(b)(2) to the Order Approving the Minor’s Compromise By way of settlement, Defendant has offered to pay the following sums to the minor Claimants: Future periodic payments to Jeyana Grant on the dates and in the amounts indicated hereafter (the “Periodic Payments™): Payable to Jeyana Grant (“Payee™) $30,000.00 guaranteed lump sum payable at age 18 (on November 11, 2029). $40,000.00 guaranteed lump sum payable at age 21 (on November 11, 2032). $50,000.00 guaranteed lump sum payable at age 24 (on November 11, 2035). $60,015.92 guaranteed lump sum payable at age 27 (on November 11, 2038). All sums set forth herein constitute damages on account of personal, physical injuries or sickness, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. Payee acknowledges that the Periodic Payments cannot be accelerated, deferred, increased, or decreased by the Payee; nor shall the Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments or any part thereof, by way of assignment or otherwise. In the event Minor Claimants pre-decease issuance of any of the above payments, Minor Claimants’ estate shall be designated as Beneficiary and all remaining payments shall be made to Minor Claimants’ estate. After the age of majority, Minor Claimants may submit a change of beneficiary in writing to the Assignee. The designation must be in a form acceptable to the Assignee. Assignment: The Defendant’s obligation to make the periodic payments described herein shall be assigned to MetLife Assignment Company, Inc. through a Qualified Assignment and funded by an annuity contract issued by Metropolitan Tower Life Insurance Company rated A+ by A.M. Best. To fund the periodic payments, the Defendant will issue a check in the amount of $112,500.00 payable to MetLife Assignment Company, Inc. and execute the Qualified Assignment and Release Agreement. ALL PAYMENTS WILL BE PAID ON THE ABOVE DUE DATES TO JEYANA GRANT WITHOUT FURTHER AUTHORIZATION FROM THE COURT.