Preview
ed MC-350EX
ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 237968 ' me‘a‘ FE m
NAME: Daniel R. Del Rio (SBN 237968) Supert 2 e
FIRMNAME: Del Rio and Caraway, P.C. Sacramento
STREET ADDRESS: 2335 American River Drive, Ste 200
CITY: Sacramento STATE: CA ZIP CODE: 95825 03N ’f 2024
TELEPHONE NO: 916.378.4705 FAXNO: 916.378.4706 caddicb
EMAIL ADDRESS: daniel@delriolawoffice.com By , Deputy
ATTORNEY FOR (Name): Rubi Sanchez, a minor
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento
24CV004717
STREET ADDRESS: 720 9th Street
MAILING ADDRESS: 720 9th Street
CITY AND ZIP CODE: Sacramento, CA 94553
BRANCH NAME: Gordon D. Schaber Sacramento County
CASE NAME: CASE NUMBER:
In re: Rubi Sanchez, a minor
[X7] No hearing date is requested.
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF ] FesmoonTe
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY pePT. T
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. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) You
may request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and
either 3g(1) or 3g(2), below, are true and 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. Petitioner (name or pseudonym®): Javier Sanchez
is the (check all boxes that apply): [__| Parent [ X ] 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.))
2. Claimant (name): Rubi Sanchez
a. Address: 1100 Nogales Street Sacramento, CA 95838
b. Date of birth: 08/20/2006 c. Age: 17 d. [X] Minor or [__] Person with a disability
(If the claimant is 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.
f. Does not have a conservator of the estate.
3. Qualification for Expedited Approval
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.
No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust.
aoow
There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.
Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the
claim is asserted or a party's insurance carrier.
Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.
0
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
12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or
(2) [x] 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
those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in
Attachment 3.)
Page10of 7
s olFomcaso """ PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Probate Codo, 6 3600, 600-3615
g i B CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF Gy aen ol S
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY sok
MC-350EX
ICASE NAME: In re: Rubi Sanchez, a minor CASE NUMBER:
4. Claim The claim of the minor or adult person with a disability:
a. [X] Is not the subject of a pending action or proceeding. (Complete items 5-23.)
b. [] Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.)
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 (exclusive of interest and costs) of (specify): $
Defendants (names:
Nationwide Insurance, the uninsured motorist carrier for the Sanchez family.
[_] Additional defendants listed on Attachment4. [__] The judgment was filed on (date):
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.)
5. Incident or accident The incident or accident occurred as follows:
a. Date: 03/06/2023 Time: 8:00 am
b. Place: South Avenue east of Dry Creek Road in Sacramento, Ca.
c. Persons involved (names):
Rubi Sanchez
[_1] 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):
Rubi Sanchez (a minor) was struck by a vehicle driven by an uninsured motorist while she walked to school.
[ Continued on Attachment 6.
7. Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Laceration on her lip,abrasion to her left face and cheek, bilateral lip pain, and headache.
[_] Continued on Attachment 7.
8. Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
She was transported via ambulance to UC Davis Medical Center where she was given x-rays. She also followed up with her
chiropractor at Sacramento Spinal Specialists which confirmed diagnoses of sprain and strain of ligaments of the thoracic spine,
sprain of the lumbar/pelvis, knee bursitis, strain of the knee, post traumatic headache, traumatic brain injury, nausea and
vomiting, dizziness,vertigo, fatigue, head abrasion, and tinnitus.
[x7] Continued on Attachment 8.
MC-350EX [Rev. January 1, 2021] Page 20of 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: In re: Rubi Sanchez, a minor CASE NUMBER:
. Extent of injuries and recovery (An oniginal or a phofocopy 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 9. 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 7, and there are no permanent
injuries.
b. [_] 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 remaining injuries and symptoms):
[] Continued on Attachment 9b.
c. [X7] 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 permanent injuries and symptoms):
Rubi continues to suffer from the permanent symptoms of the traumatic brain injury that she sustained as a result of
the incident on 3/16/23. This includes permanently wearing prism lenses prescribed by Dr. Fong. Her vision problems
related to her traumatic brain injury are permanent and debilitating.
[] Continued on Attachment 9c.
10.[X] 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): $ 100,000
b. The defendants and amounts offered by each are as follows (specify):
Defendants (names) Amounts
Nationwide Insurance $ 100,000
$
$
$
[ Additional defendants and amounts offered are listed on Attachment 11b.
c. The terms of settlement are described on Attachment 11c. (If the settlement is to be paid in installments, both the total amount
and the present value of the settlement must be included.)
12. Settlement payments to others
a. [X] 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. [_] One or more of the defendants named in item 11b have also offered to pay money to a person or persons other than
claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury.
(1) The total amount offered by all defendants to others is (specify): $
(2) [ Petitioner would receive money under the proposed settiement.
(3) The settilement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
NHNHA
[ 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.
MC-350EX [Rev. January 1, 2021] Page3of 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: In re: Rubi Sanchez, a minor CASE NUMBER:
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: $ 53,801.38
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): (€3 2,113.71)
(3) Total of negotiated, contractual, or statutory reductions, if any: $ 33,400.21)
(4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 0
(5) Total amount of statutory or contractual liens, if any: $ 20,400.29
(Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5)
in Aftachment 13a.)
b. (1) [X_] None of the claimant's medical expenses have been paid by Medicare.
(2) [_] 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) [x7] Medi-Cal paid some or all of claimant's medical expenses.
(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 [_] is attached [__] was filed in this matter on (date):
(b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $ 1,585.29
(Attach a copy of the final Medi-Cal 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: $
(See instructions for item 15.)
f. (1) [_] There are no statutory or contractual liens for payment of the claimant's medical expenses.
(2) [x] 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: $ 18,815
g. (Select (1) or (2) below.)
(1) [X] Latest statements from all medical service providers are attached as Attachment 13g.
(2) [_] All 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: $ 33,333.33
(If fees are requested, aftach as Attachment 14a a declaration from the attomey explaining the basis for the request, including a
discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attomey fee
agreement in 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:
ltems Payees (names) Amounts
Records Del Rio & Caraway, P.C. $ 109.1
Postage Del Rio & Caraway, P.C. $ 26.39
File Set Up Del Rio & Caraway, P.C. $ 350
$
$
$
$
$
[ Continued on Attachment 14b. Total: § 485.49
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] Paged of 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: In re: Rubi Sanchez, a minor CASE NUMBER:
15. Reimbursement of fees and expenses paid by petitioner
a. [x] Petitioner has paid none of the fees or expenses listed in items 13 and 14 for which reimbursement is requested.
b. [] Petitioner has paid the following total amounts of the claimant's fees and expenses for which reimbursement is requested.
(1) [_] Medical expenses listed in item 13: $
(2) [] Attorney's fees included in the total fee amount shown in item 14a: $
(3) [_] Other expenses included in the total shown in item 14b: $
(Attach proofs of the fees and expenses incurred and payments made, e.qg., bills or invoices, Total: $
canceled checks, credit card statements, explanations of benefits from insurers, efc.)
16. Net balance of proceeds remaining for claimant
The balance of the proceeds of the proposed settiement or judgment remaining for the claimant
after payment or reimbursement of all requested fees and expenses is (specify): $ 45,780.89
17. Summary
a. Gross amount of proceeds of settlement or judgment for claimant: $ 100,000
b. Medical expenses to be paid from proceeds of settlement or judgment: $ 20,400.29
c. Attorney's fees to be paid from proceeds of settlement or judgment: $ 33,333.33
d. Expenses (other than medical) to be paid from proceeds of settlement
or judgment: $ 485.49
Total fees and expenses to be paid from proceeds of settlement or
judgment (add (b), (c), and (d)): $ 54,219.11)
Balance of proceeds of settlement or judgment available for claimant
after payment of all fees and expenses (subtract (e) from (a)): $ 45,780.89
18. Information about attorney representing or assisting petitioner
Theattorney [X ]isnot [ ]is representing or employed by another party involved in this matter.
(If you answered "is," identify the other party and explain the relationship in Attachment 18a. If the other party is a defendant,
you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1
and Cal. Rules of Court, rule 7.950.5(a)(6).)
The attorney [[X_] has neither received nor expects to receive [__] has received or expects to receive attorney's fees or
other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to
this petition (if you answered "has received or expects to receive," identify the person who paid or will pay the fees or other
compensation, the amounts paid or to be paid, and the dates of payment or expected payment):
Amount
From Whom Paid or Expected (name) Date Paid or Expected Paid or Expected
$
$
$
$
$
$
$
[] Continued on Attachment 18b. Total: $
MC-350EX [Rev. January 1, 2021] Page5of7
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: In re: Rubi Sanchez, a minor CASE NUMBER:
19. Disposition of balance to claimant (check either a 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 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 all that apply):
@ [1% 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 1% 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).
© [1% 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. [X'] 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 all that apply):
(1) [] A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability 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) [x] $45,780.89 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).
oo B R of money 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 19b(3).
@[ 1% 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). (Value of minor's entire estate, including the money or
property to be delivered, must not exceed $5,000.)
G [ 18 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).
® 1% 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
exceed $20,000.)
MEZ]S 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 19b(7).
® [ 1% 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).
(ONEE ] be paid or transferred to the adult person with a disability. The money or other property is
specified in Attachment 19b(9).
MC-350EX [Rev. January 1, 2021] Page 6 0of 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: In re: Rubi Sanchez, a minor CASE NUMBER:
20.[ ] Additional orders
Petitioner requests the following additional orders (specify and explain):
[_] Continued on Attachment 20.
21.[_] |, the claimant named in item 2, consent to the order or judgment requested in this petition.
(Required if the claimant is an adult with a disability who has the capacity, under Probate Code section 812, to consent to the
order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.))
Date:
(TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT)
22. Petitioner recommends the proposed compromise, settiement, 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:
Date: 1/24/2024 M
Daniel R. Del Rio ’
(TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY)
| declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date: 1/24/2024
Javier Sanchez ’
(TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER)
MC-350EX [Rev. January 1, 2021] Page 7 of 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-025
SHORT TITLE: (CASE NUMBER:
[ Inre: Rubi Sanchez, a minor
ATTACHMENT (Number): 8
(This Attachment may be used with any Judicial Council form.)
She was also seen by Rincon Physical Medicine and Rehabilitation for a neurooptometry examination where
she was diagnosed with traumatic brain injury.
(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page 1 of
Attachment are made under penalty of perjury.) (Add pages & required)
Form Approved for Optional Use ATTACHMENT www.courtinfo.ca.gov
Judicial Council of Califoria
MC-025 [Rev. July 1, 2008] to Judicial Council Form
MC-025
SHORT TITLE: CASE NUMBER:
| Inre: Rubi Sanchez, a minor
ATTACHMENT (Number): 13(a)
(This Attachment may be used with any Judicial Council form.)
The gross medical bills incurred by Rubi Sanchez, a minor, in this matter totaled $53,801.38.
These bills arise from her emergency transportation and emergency room visit, chiropractic treatment, MRI
imaging, and Rincon Physical Medicine and Rehabilitation. All records of treatment are attached hereto for the
Court’s review. See attachment 9.
Rubi's health insurance paid $31,267.50 towards her emergency room bill as well as $674.00 towards the
professional billing. This leaves Rubi with a zero balance from UC Davis.
Rubi Sanchez, a minor received chiropractic treatment at Sacramento Spinal Specialists. The outstanding
amount of the chiropractic bills is $4,548.00.
Rubi Sanchez, a minor, had MRI studies performed at a cost of an outstanding $8,200.00
Rubi Sanchez, a minor, treated at Rincon and has an outstanding balance of $6,067.00.
(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page i of
Attachment are made under penalty of perjury.) (Add pages as required)
Form Approved for Optional Use A]TACHMENT www.courtinfo.ca.gov
Judicial Council
of Califomia & o 3
MC-025 [Rev. July 1, 2009] to Judicial Council Form
MC-025
SHORT TITLE: (CASE NUMBER:
[ Inre: Rubi Sanchez, a minor
ATTACHMENT (Number): 9
(This Attachment may be used with any Judicial Council form.)
See attached medical reports.
(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page | of
Attachment are made under penalty of perjury.)
(Add pages as required)
Form Approved for
Judicial Council of
Optional Use
Califomia ATTACHMENT www.courtinfo.ca.gov
'MC-025 [Rev. July 1, 2009] to Judicial Council Form
Billing Review
Sacramento Fire Dept
5770 Freeport Bl ; Suite 200; Sacramento, CA 95822
Date:03/16/2023 Call #:022208 Booklet:106896336 Branch: Station 17
Shift:A Shift Bill Status:Ready To Bill Time Zone:America/Los_Angeles
Call Information: # Patients Transported
g2 In My Unit: 3 1
Billing Disposition: Treated/Transported
Initial Patient Acuity: Emergent (Yellow) # Patients at Scene: 1
Unit #: M17 - Medic 17, Ground-Ambulance (41) Trip Type: Initial Trip
Call Received: 08:15:32
Run Type To Scene: Emergent (Immediate Response)
Dispatched: 08:17:33
Incident Facility:
En Route:
Incident Location: DRY CREEK RD/SOUTH AV - Sacramento, CA 95838-4486 (Sacramento County) At 08:18:15
Type: N/A Staging Area:
Incident Location On Scene: 08:23:52
Receiving Facility: UG Davis Medical Center (Hospital) - 2315 Stockton Bivd. - Sacramento, CA 95816 Patlent Contact: 08:24:52
Facility Address: 2315 Stockton Bivd. - Sacramento, CA 95816 NPI: 1710918545 Transfer of EMS
Destination Type: Hospital Emergency Department Patient Care:
Nearest/Most Accessible Facility Left Scene: 08:31:29
Dest. Reason: 08:49:56
At Destination:
Hospital Capability: Hospital (General)
Condition of Patient At Destination: Unchanged Destination Patient
Transfer of Care: 09:10:55
Registration # 8296702
In Service: 09:20:06
Mileage:
Time On Scene: 8 Min
Calculated Mileage: 7.44
Time to Destination: 32 Min
Crew Members: Clayton DeConte, Licensed Paramedic(DOC); Christopher Mitchell, EMT Basic(DS) Total Time of Run: 62 Min
(DH); ERIC ELY, EMT Basic; JILL KLEIN, Licensed Paramedic; Cameron
Terpstra, Licensed Paramedic
Moved to Amb By: Stretcher Transport Position: Semi/Full Fowlers From Amb By: Stretcher
Other Unit On Scene: E17 - Engine 17, Ground-Ambulance, (41)
Call Origin: N/A Lights/Siren: Scene - Lights and Sirens, Destination - No Lights and Sirens
Pre-Arrival Activation: No Time:
Other Units On Scene: E17, E17
Patient Information:
DOB: 08/20/2006
Name: RUBI SANCHEZ Gender:Female
o
Address: x 1100 Nogales st - sacramento, CA 85838 i 16 Years
County: Sacramento Weight: 100.0 Ibs 45.36 kg
Broselow:
;’r::'l‘l.
SSN:
Driver License:
Current Meds: Comments:
Env Allergies: Comments:
Med Allergies: Comments:
Patient Physician:
Advance Directives:
Recent Travel: No
PMH:
Comment:
Patient Physical Limitations:
Comment:
©2023 Sansio Sacramento Fire Dept BK: 106896336 PCR 29 of 100
March 20, 2023
Clinical:
Onset Date/Time:
Dispatch Reason (EMD): 29D2M AUTO/PED
Special Conditions: Required Stretcher - Yes; Severe Pain - No; Alterations of Cognition - No
Chief Complaint (Primary): head, knee, shoulder pain post mva Duration: 30 Minutes
Provider Impression: T14.90XA (Traumatic Injury)
Mechanism of Injury:
Injuries:
Protocol 1: Trauma-Adult Protocol 2:
Assessments:
Time Employee Type Summary
08:26:52 Terpstra, ABC Alrway:
Cameron General: Patent: Yes
" Breathing:
Rate: Normal: Yes
Quality: Unlabored: Yes
Lung Sounds: Left: Clear: Yes
Lung Sounds: Right: Clear: Yes
Circulation:
General: Normal: Yes
Skin Capillary Refill: Normal
Skin Color: Normal: Yes
Skin Temperature: Normal: Yes
Skin Condition: Normal: Yes
082652 DeConte, Clayton Neurological _ AVPU: Alert
Mental Status: Normal: Yes
Neurological: All Neuro: Normal
Vitals:
Time Employee Summary
08:34:33 Ekg Device, BP: 101/37
LIFEPAK 15 MAP: 58
Pulse: 76
Resp: 16
SPO2: 98
Pain: 6 Pain Scale: Numeric (0-10)
+ M (6) = 15 - Adult
Coma Score: E (4) +V (5)
Glasgow
08:38:55 Ekg Device, BP: 128/ 79
LIFEPAK 156 MAP: 95
Pulse: 80
08:44:02 Ekg Device, BP: 119/ 70
LIFEPAK 15 MAP: 86
Pulse: 71
Treatments/Medications:
Time Employee Summary
08:26:52 DeConte, Clayton Treatment- ALS Assessment
Success: Yes
Level: ALS
083152 DeConte, Clayton Treatment- Cervical Collar Only
Success: Yes
Level: BLS
08:34:39 Ekg Device, Treatment- ECG 4 Lead
LIFEPAK 15 Success:
Level: ALS1
Supply
M
Preview
ed MC-350EX ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 237968 ' me‘a‘ FE m NAME: Daniel R. Del Rio (SBN 237968) Supert 2 e FIRMNAME: Del Rio and Caraway, P.C. Sacramento STREET ADDRESS: 2335 American River Drive, Ste 200 CITY: Sacramento STATE: CA ZIP CODE: 95825 03N ’f 2024 TELEPHONE NO: 916.378.4705 FAXNO: 916.378.4706 caddicb EMAIL ADDRESS: daniel@delriolawoffice.com By , Deputy ATTORNEY FOR (Name): Rubi Sanchez, a minor SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento 24CV004717 STREET ADDRESS: 720 9th Street MAILING ADDRESS: 720 9th Street CITY AND ZIP CODE: Sacramento, CA 94553 BRANCH NAME: Gordon D. Schaber Sacramento County CASE NAME: CASE NUMBER: In re: Rubi Sanchez, a minor [X7] No hearing date is requested. PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF ] FesmoonTe CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY pePT. T 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. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) You may request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and either 3g(1) or 3g(2), below, are true and 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. Petitioner (name or pseudonym®): Javier Sanchez is the (check all boxes that apply): [__| Parent [ X ] 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.)) 2. Claimant (name): Rubi Sanchez a. Address: 1100 Nogales Street Sacramento, CA 95838 b. Date of birth: 08/20/2006 c. Age: 17 d. [X] Minor or [__] Person with a disability (If the claimant is 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. f. Does not have a conservator of the estate. 3. Qualification for Expedited Approval 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. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust. aoow There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier. 0 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 12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or (2) [x] 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 those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in Attachment 3.) Page10of 7 s olFomcaso """ PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Probate Codo, 6 3600, 600-3615 g i B CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF Gy aen ol S JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY sok MC-350EX ICASE NAME: In re: Rubi Sanchez, a minor CASE NUMBER: 4. Claim The claim of the minor or adult person with a disability: a. [X] Is not the subject of a pending action or proceeding. (Complete items 5-23.) b. [] Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.) 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 (exclusive of interest and costs) of (specify): $ Defendants (names: Nationwide Insurance, the uninsured motorist carrier for the Sanchez family. [_] Additional defendants listed on Attachment4. [__] The judgment was filed on (date): (Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.) 5. Incident or accident The incident or accident occurred as follows: a. Date: 03/06/2023 Time: 8:00 am b. Place: South Avenue east of Dry Creek Road in Sacramento, Ca. c. Persons involved (names): Rubi Sanchez [_1] 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): Rubi Sanchez (a minor) was struck by a vehicle driven by an uninsured motorist while she walked to school. [ Continued on Attachment 6. 7. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Laceration on her lip,abrasion to her left face and cheek, bilateral lip pain, and headache. [_] Continued on Attachment 7. 8. Treatment The claimant received the following care and treatment for the injuries described in item 7 (describe): She was transported via ambulance to UC Davis Medical Center where she was given x-rays. She also followed up with her chiropractor at Sacramento Spinal Specialists which confirmed diagnoses of sprain and strain of ligaments of the thoracic spine, sprain of the lumbar/pelvis, knee bursitis, strain of the knee, post traumatic headache, traumatic brain injury, nausea and vomiting, dizziness,vertigo, fatigue, head abrasion, and tinnitus. [x7] Continued on Attachment 8. MC-350EX [Rev. January 1, 2021] Page 20of 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: In re: Rubi Sanchez, a minor CASE NUMBER: . Extent of injuries and recovery (An oniginal or a phofocopy 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 9. 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 7, and there are no permanent injuries. b. [_] 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 remaining injuries and symptoms): [] Continued on Attachment 9b. c. [X7] 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 permanent injuries and symptoms): Rubi continues to suffer from the permanent symptoms of the traumatic brain injury that she sustained as a result of the incident on 3/16/23. This includes permanently wearing prism lenses prescribed by Dr. Fong. Her vision problems related to her traumatic brain injury are permanent and debilitating. [] Continued on Attachment 9c. 10.[X] 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): $ 100,000 b. The defendants and amounts offered by each are as follows (specify): Defendants (names) Amounts Nationwide Insurance $ 100,000 $ $ $ [ Additional defendants and amounts offered are listed on Attachment 11b. c. The terms of settlement are described on Attachment 11c. (If the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.) 12. Settlement payments to others a. [X] 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. [_] One or more of the defendants named in item 11b have also offered to pay money to a person or persons other than claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. (1) The total amount offered by all defendants to others is (specify): $ (2) [ Petitioner would receive money under the proposed settiement. (3) The settilement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts NHNHA [ 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. MC-350EX [Rev. January 1, 2021] Page3of 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: In re: Rubi Sanchez, a minor CASE NUMBER: 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: $ 53,801.38 (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): (€3 2,113.71) (3) Total of negotiated, contractual, or statutory reductions, if any: $ 33,400.21) (4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 0 (5) Total amount of statutory or contractual liens, if any: $ 20,400.29 (Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5) in Aftachment 13a.) b. (1) [X_] None of the claimant's medical expenses have been paid by Medicare. (2) [_] 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) [x7] Medi-Cal paid some or all of claimant's medical expenses. (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 [_] is attached [__] was filed in this matter on (date): (b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ 1,585.29 (Attach a copy of the final Medi-Cal 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: $ (See instructions for item 15.) f. (1) [_] There are no statutory or contractual liens for payment of the claimant's medical expenses. (2) [x] 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: $ 18,815 g. (Select (1) or (2) below.) (1) [X] Latest statements from all medical service providers are attached as Attachment 13g. (2) [_] All 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: $ 33,333.33 (If fees are requested, aftach as Attachment 14a a declaration from the attomey explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attomey fee agreement in 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: ltems Payees (names) Amounts Records Del Rio & Caraway, P.C. $ 109.1 Postage Del Rio & Caraway, P.C. $ 26.39 File Set Up Del Rio & Caraway, P.C. $ 350 $ $ $ $ $ [ Continued on Attachment 14b. Total: § 485.49 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] Paged of 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: In re: Rubi Sanchez, a minor CASE NUMBER: 15. Reimbursement of fees and expenses paid by petitioner a. [x] Petitioner has paid none of the fees or expenses listed in items 13 and 14 for which reimbursement is requested. b. [] Petitioner has paid the following total amounts of the claimant's fees and expenses for which reimbursement is requested. (1) [_] Medical expenses listed in item 13: $ (2) [] Attorney's fees included in the total fee amount shown in item 14a: $ (3) [_] Other expenses included in the total shown in item 14b: $ (Attach proofs of the fees and expenses incurred and payments made, e.qg., bills or invoices, Total: $ canceled checks, credit card statements, explanations of benefits from insurers, efc.) 16. Net balance of proceeds remaining for claimant The balance of the proceeds of the proposed settiement or judgment remaining for the claimant after payment or reimbursement of all requested fees and expenses is (specify): $ 45,780.89 17. Summary a. Gross amount of proceeds of settlement or judgment for claimant: $ 100,000 b. Medical expenses to be paid from proceeds of settlement or judgment: $ 20,400.29 c. Attorney's fees to be paid from proceeds of settlement or judgment: $ 33,333.33 d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ 485.49 Total fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): $ 54,219.11) Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): $ 45,780.89 18. Information about attorney representing or assisting petitioner Theattorney [X ]isnot [ ]is representing or employed by another party involved in this matter. (If you answered "is," identify the other party and explain the relationship in Attachment 18a. If the other party is a defendant, you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1 and Cal. Rules of Court, rule 7.950.5(a)(6).) The attorney [[X_] has neither received nor expects to receive [__] has received or expects to receive attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition (if you answered "has received or expects to receive," identify the person who paid or will pay the fees or other compensation, the amounts paid or to be paid, and the dates of payment or expected payment): Amount From Whom Paid or Expected (name) Date Paid or Expected Paid or Expected $ $ $ $ $ $ $ [] Continued on Attachment 18b. Total: $ MC-350EX [Rev. January 1, 2021] Page5of7 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: In re: Rubi Sanchez, a minor CASE NUMBER: 19. Disposition of balance to claimant (check either a 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 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 all that apply): @ [1% 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 1% 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). © [1% 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. [X'] 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 all that apply): (1) [] A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability 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) [x] $45,780.89 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). oo B R of money 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 19b(3). @[ 1% 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). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) G [ 18 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). ® 1% 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 exceed $20,000.) MEZ]S 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 19b(7). ® [ 1% 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). (ONEE ] be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 19b(9). MC-350EX [Rev. January 1, 2021] Page 6 0of 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: In re: Rubi Sanchez, a minor CASE NUMBER: 20.[ ] Additional orders Petitioner requests the following additional orders (specify and explain): [_] Continued on Attachment 20. 21.[_] |, the claimant named in item 2, consent to the order or judgment requested in this petition. (Required if the claimant is an adult with a disability who has the capacity, under Probate Code section 812, to consent to the order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.)) Date: (TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT) 22. Petitioner recommends the proposed compromise, settiement, 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: Date: 1/24/2024 M Daniel R. Del Rio ’ (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY) | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: 1/24/2024 Javier Sanchez ’ (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) MC-350EX [Rev. January 1, 2021] Page 7 of 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-025 SHORT TITLE: (CASE NUMBER: [ Inre: Rubi Sanchez, a minor ATTACHMENT (Number): 8 (This Attachment may be used with any Judicial Council form.) She was also seen by Rincon Physical Medicine and Rehabilitation for a neurooptometry examination where she was diagnosed with traumatic brain injury. (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page 1 of Attachment are made under penalty of perjury.) (Add pages & required) Form Approved for Optional Use ATTACHMENT www.courtinfo.ca.gov Judicial Council of Califoria MC-025 [Rev. July 1, 2008] to Judicial Council Form MC-025 SHORT TITLE: CASE NUMBER: | Inre: Rubi Sanchez, a minor ATTACHMENT (Number): 13(a) (This Attachment may be used with any Judicial Council form.) The gross medical bills incurred by Rubi Sanchez, a minor, in this matter totaled $53,801.38. These bills arise from her emergency transportation and emergency room visit, chiropractic treatment, MRI imaging, and Rincon Physical Medicine and Rehabilitation. All records of treatment are attached hereto for the Court’s review. See attachment 9. Rubi's health insurance paid $31,267.50 towards her emergency room bill as well as $674.00 towards the professional billing. This leaves Rubi with a zero balance from UC Davis. Rubi Sanchez, a minor received chiropractic treatment at Sacramento Spinal Specialists. The outstanding amount of the chiropractic bills is $4,548.00. Rubi Sanchez, a minor, had MRI studies performed at a cost of an outstanding $8,200.00 Rubi Sanchez, a minor, treated at Rincon and has an outstanding balance of $6,067.00. (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page i of Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use A]TACHMENT www.courtinfo.ca.gov Judicial Council of Califomia & o 3 MC-025 [Rev. July 1, 2009] to Judicial Council Form MC-025 SHORT TITLE: (CASE NUMBER: [ Inre: Rubi Sanchez, a minor ATTACHMENT (Number): 9 (This Attachment may be used with any Judicial Council form.) See attached medical reports. (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page | of Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Judicial Council of Optional Use Califomia ATTACHMENT www.courtinfo.ca.gov 'MC-025 [Rev. July 1, 2009] to Judicial Council Form Billing Review Sacramento Fire Dept 5770 Freeport Bl ; Suite 200; Sacramento, CA 95822 Date:03/16/2023 Call #:022208 Booklet:106896336 Branch: Station 17 Shift:A Shift Bill Status:Ready To Bill Time Zone:America/Los_Angeles Call Information: # Patients Transported g2 In My Unit: 3 1 Billing Disposition: Treated/Transported Initial Patient Acuity: Emergent (Yellow) # Patients at Scene: 1 Unit #: M17 - Medic 17, Ground-Ambulance (41) Trip Type: Initial Trip Call Received: 08:15:32 Run Type To Scene: Emergent (Immediate Response) Dispatched: 08:17:33 Incident Facility: En Route: Incident Location: DRY CREEK RD/SOUTH AV - Sacramento, CA 95838-4486 (Sacramento County) At 08:18:15 Type: N/A Staging Area: Incident Location On Scene: 08:23:52 Receiving Facility: UG Davis Medical Center (Hospital) - 2315 Stockton Bivd. - Sacramento, CA 95816 Patlent Contact: 08:24:52 Facility Address: 2315 Stockton Bivd. - Sacramento, CA 95816 NPI: 1710918545 Transfer of EMS Destination Type: Hospital Emergency Department Patient Care: Nearest/Most Accessible Facility Left Scene: 08:31:29 Dest. Reason: 08:49:56 At Destination: Hospital Capability: Hospital (General) Condition of Patient At Destination: Unchanged Destination Patient Transfer of Care: 09:10:55 Registration # 8296702 In Service: 09:20:06 Mileage: Time On Scene: 8 Min Calculated Mileage: 7.44 Time to Destination: 32 Min Crew Members: Clayton DeConte, Licensed Paramedic(DOC); Christopher Mitchell, EMT Basic(DS) Total Time of Run: 62 Min (DH); ERIC ELY, EMT Basic; JILL KLEIN, Licensed Paramedic; Cameron Terpstra, Licensed Paramedic Moved to Amb By: Stretcher Transport Position: Semi/Full Fowlers From Amb By: Stretcher Other Unit On Scene: E17 - Engine 17, Ground-Ambulance, (41) Call Origin: N/A Lights/Siren: Scene - Lights and Sirens, Destination - No Lights and Sirens Pre-Arrival Activation: No Time: Other Units On Scene: E17, E17 Patient Information: DOB: 08/20/2006 Name: RUBI SANCHEZ Gender:Female o Address: x 1100 Nogales st - sacramento, CA 85838 i 16 Years County: Sacramento Weight: 100.0 Ibs 45.36 kg Broselow: ;’r::'l‘l. SSN: Driver License: Current Meds: Comments: Env Allergies: Comments: Med Allergies: Comments: Patient Physician: Advance Directives: Recent Travel: No PMH: Comment: Patient Physical Limitations: Comment: ©2023 Sansio Sacramento Fire Dept BK: 106896336 PCR 29 of 100 March 20, 2023 Clinical: Onset Date/Time: Dispatch Reason (EMD): 29D2M AUTO/PED Special Conditions: Required Stretcher - Yes; Severe Pain - No; Alterations of Cognition - No Chief Complaint (Primary): head, knee, shoulder pain post mva Duration: 30 Minutes Provider Impression: T14.90XA (Traumatic Injury) Mechanism of Injury: Injuries: Protocol 1: Trauma-Adult Protocol 2: Assessments: Time Employee Type Summary 08:26:52 Terpstra, ABC Alrway: Cameron General: Patent: Yes " Breathing: Rate: Normal: Yes Quality: Unlabored: Yes Lung Sounds: Left: Clear: Yes Lung Sounds: Right: Clear: Yes Circulation: General: Normal: Yes Skin Capillary Refill: Normal Skin Color: Normal: Yes Skin Temperature: Normal: Yes Skin Condition: Normal: Yes 082652 DeConte, Clayton Neurological _ AVPU: Alert Mental Status: Normal: Yes Neurological: All Neuro: Normal Vitals: Time Employee Summary 08:34:33 Ekg Device, BP: 101/37 LIFEPAK 15 MAP: 58 Pulse: 76 Resp: 16 SPO2: 98 Pain: 6 Pain Scale: Numeric (0-10) + M (6) = 15 - Adult Coma Score: E (4) +V (5) Glasgow 08:38:55 Ekg Device, BP: 128/ 79 LIFEPAK 156 MAP: 95 Pulse: 80 08:44:02 Ekg Device, BP: 119/ 70 LIFEPAK 15 MAP: 86 Pulse: 71 Treatments/Medications: Time Employee Summary 08:26:52 DeConte, Clayton Treatment- ALS Assessment Success: Yes Level: ALS 083152 DeConte, Clayton Treatment- Cervical Collar Only Success: Yes Level: BLS 08:34:39 Ekg Device, Treatment- ECG 4 Lead LIFEPAK 15 Success: Level: ALS1 Supply M