Preview
MC-351
ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 292233 FOR COURT USE ONLY
NAME: Mahyar Roshani, Esq.
FIRMNAME: jacoby and Meyers Attorneys LLP
STREET ADDRESS: 10900 Wilshire Blvd., 15th Floor
CITY: Los Angeles STATE: CA ZIP CODE: 90024
TELEPHONE NO.: (424) 226-1667 FAX NO.:
EMAIL ADDRESS: mroshani@jacobyandmeyers.com
ATTORNEY FOR (Name): Omar Alexander Khan
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento
STREET ADDRESS: 720 gth Street
MAILING ADDRESS: 720 gth Street
CITY AND ZIP CODE: Sacramento, CA 95814
BRANCH NAME: Sacramento County Superior Court
CASE NAME:
In the Matter of Omar Alexander Khan
CASE NUMBER:
ORDER APPROVING COMPROMISE OF CLAIM OR ACTION 24cV 00571\
OR DISPOSITION OF PROCEEDS OF JUDGMENT HEARING DATE, IF ANY: DEPT.:
FOR MINOR OR PERSON WITH A DISABILITY
1. Hearing w
a. [__] 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: '-n
2. Petitioner (name or pseudonym*): John Mohammad Khan ><
is the (check all relationships or representative capacities that apply): [X] parent [ ] guardian ad litem*
TX] 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): Omar Alexander Khan
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”)):
Habiba Hashimi,
THE COURT FINDS
5. X7
[ 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. [X] The claimant's consent to this order is not required because the claimant is a minor, a conservatee, or a person who lacks
o the order within the meaning of Probate Code section 812.
Page 1 of 4
J i :
SuccalCaueiof Caioma
MC-351 [Rev. January
\ + >, “@BDER/APPROVING
1, 2021 O/b
COMPROMISE OF CLAIM OR ACTION
DISPOSITION OF PROCEEDS OF JUDGMENT
Probate Code, § 500, 9606- 3613
Cal. Rules of Court, rules.aggi’?:,c;gge
/L FOR MINOR OR PERSON WITH A DISABILITY
MC-351
CASE NAME: In the Matter of Amaira Aioko Daniels 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: $ 60.000 .
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: $ 20.000 payable to (specify):
Jacoby and Meyers Attorneys LLP
(2) [X] Reimbursement for medical and all other expenses paid by the petitioner or the petitioner's
attorney in the total amount of: $ 1.123.20
* (3) [X] Medical, hospital, ambulance, nursing, and other similar expenses payable directly to
providers as follows, in the total amount of: $ 16.015.09
= (a) Payee (name): U.C. Davis Medical Center
(i) address:
P.O. Box 743481
Los Angeles CA 90074-3481
(ii) Amount: $ 8.056.16
(b) Payee (name): Eauian/Kaiser
(i) address:
9390 Bunsen Parkway
Lousville, KY 40220
(ii) Amount: $ 7.958.93
[ 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).
(6) [X] Total allowance for fees and expenses from the settlement or judgment: $ 37.138.29
MC-351 [Rev. January 1, 2021] Page 2 of 4
ORDER APPROVING COMPROMISE OF CLAIM OR ACTION
OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY
MC-351
CASE NAME: In the Matter of Amaira Aioko Daniels 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: $ 22.861.71
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) X By the following method(s) (describe each method, including the amount to be disbursed by each):
Check payable to Jacoby and Meyers Attorneys LLP in the amount of $37,138.29 for Legal Fees, Medical Payments
and Costs. A check for the remaining balance of $22,861.70, which will be used to purchase a structured settlement
annuity, per Attachment 8b(2).
X Continued on Attachment 8b(2).
(3) [_] fmoney 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 PRESSIIIS
OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY
MC-351
CASE NAME: In the Matter of Amaira Aioko Daniels 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) [__] The blocked account or accounts belong to a minor, who was born on (date):
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 depository, 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: $ X 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
NGB [Row Janaley 2020 ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Pegeiots
OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY
ATTACHMENT 8b(2) To MC-351 ¢ ATTACHMENT 18b(3) TO MC-350 e
ATTACHMENT 19b(3) To MC-350EX
Terms and Conditions of the Annuity for Omar Khan
The Court so orders that $23,528.38 be paid by Defendant and/or its Insurer (“Payor”) to purchase
a structured settlement annuity, in which MetLife Assignment Company (€ Assignee) will provide
for the following Periodic Payments to be made by Metropolitan Tower Life Insurance Company
(€ Annuity Issuer), an A+ (Superior) by A.M. Best. The details of the periodic payments of which
will be set forth below. All sums constitute damages on account of personal physical injuries
arising from an occurrence within the meaning of Section 104(a)(2) of the Internal Revenue Code.
The periodic payment schedule is as follows:
PAYEE: OMAR KHAN
Lump Sum Payments
$25,418.01 guaranteed lump sum payment at age 18 on 09/05/2027
FUNDING INSTRUCTIONS:
Check Amount: $23,528.38
Check Payable To: METLIFE ASSIGNMENT COMPANY, INC.
Tax ID#: 38-4035918
Send Check To: Tory Owens Structured Settlements
4712 Admiralty Way, Suite 434
Marina Del Rey, CA 90292
The future periodic payment amounts outlined herein are guaranteed based upon a projected
annuity purchase date of 04/26/2024. Interest rates are volatile, and the above periodic payments
may vary until locked in, which is a commitment to purchase; therefore, IF. THE RATE IS NOT
LOCKED IN OR LATE FUNDING OCCURS IT MAY REQUIRE REVISION OF THE ABOVE PERIODIC
PAYMENTS. Furthermore, any delay in funding the annuity may result in a delay of the payment
dates or change in payment amounts. Any revisions to the periodic payments shall be recorded
in the settlement agreement and release or the Addendum to the Settlement Agreement and
Release, and/or qualified assignment document and annuity contract without the need of
obtaining an amended Petition/Court Order/Infants Compromise Order. The Assignee and
Annuity Owner are expressly authorized to make any date adjustments if there is a funding delay
and reflect such date changes in the annuity contract and the qualified assignment agreement.
Payee acknowledges and agrees that the Defendant(s) and/or the PAYOR shall make a "qualified
assignment"”, within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as
amended, of the Defendant's and/or the PAYOR's liability to make the Periodic Payments required
herein. Any such assignment, shall be accepted by the Payee without right of rejection and shall
completely release and discharge the Defendant(s) and the PAYOR from such obligations
hereunder as are assigned MetLife Assignment Company ("Assignee"). The Payee recognizes that,
in the event of such an assignment, the Assignee shall be the sole obligor with respect to the
Periodic Payments assigned, and that all other releases that pertain to the liability of the
Defendant(s) and the PAYOR shall thereupon become final, irrevocable and absolute.
Page 1 of 2
If the liability to make the periodic payments is assigned by way of a “qualified assignment.”
A) Periodic payments from the Assignee cannot be accelerated, deferred, increased
or decreased by Payee;
B) The periodic payments from the Assignee will be fixed and determinable and may
not be varied by any party;
Q) The Assignee does not provide to the Payee rights against the Assignee greater
than those of a general creditor;
D) The Assignee’s obligation for payment of the periodic payments is no greater than
the obligation of the person or entity originally liable (whether by suit or
agreement) for payment and from whom the obligation was assigned.
The sole obligor of the Periodic payments, whether it is the Defendant(s), the PAYOR, and/or the
Assignee, reserves the right to fund the liability to make the Periodic Payments by purchasing an
annuity through Metropolitan Tower Life Insurance Company ("Annuity Issuer"). The
Defendant(s), the PAYOR, or in the event of an assignment the Assignee, shall be the sole owner
of the annuity and have all rights in it. Said owner of the annuity may have Metropolitan Tower
Life Insurance Company mail payments direct to the Payee. Payee shall be responsible for
maintaining a current mailing address for Payee with Metropolitan Tower Life Insurance Company
The obligation of the Defendant(s), the PAYOR, or in the event of an assignment, the obligation of
its Assignee, to make each Periodic Payment shall be discharged upon the mailing of a valid check
in the amount of such payment as stated herein to the designated address of the Payee. If the
Payee or Beneficiary notifies the Assignee that any such check or electronic funds transfer was
not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action and,
upon confirmation that such check was not previously negotiated or electronic funds transfer
deposited, shall have the Annuity Issuer process a replacement payment.
Any payments to be made after the death of any Payee pursuant to the terms of this Agreement
shall be made to such person or entity as shall be designated in writing by Claimant, upon reaching
the age of majority, to the Insurer's Assignee. If no person or entity is so designated by Claimant,
or if the person designated is not living at the time of the Payee's death, such payments shall be
made to the estate of the Payee. No such designation, nor any revocation thereof, shall be
effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The
designation must be in a form acceptable to the Insurer's Assignee before such payments are
made.
Page 2 of 2
RECE
CiVIL DRIOPVEDB0
HHMAR 25 PM 3: g
Preview
MC-351 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 292233 FOR COURT USE ONLY NAME: Mahyar Roshani, Esq. FIRMNAME: jacoby and Meyers Attorneys LLP STREET ADDRESS: 10900 Wilshire Blvd., 15th Floor CITY: Los Angeles STATE: CA ZIP CODE: 90024 TELEPHONE NO.: (424) 226-1667 FAX NO.: EMAIL ADDRESS: mroshani@jacobyandmeyers.com ATTORNEY FOR (Name): Omar Alexander Khan SUPERIOR COURT OF CALIFORNIA, COUNTY OF Sacramento STREET ADDRESS: 720 gth Street MAILING ADDRESS: 720 gth Street CITY AND ZIP CODE: Sacramento, CA 95814 BRANCH NAME: Sacramento County Superior Court CASE NAME: In the Matter of Omar Alexander Khan CASE NUMBER: ORDER APPROVING COMPROMISE OF CLAIM OR ACTION 24cV 00571\ OR DISPOSITION OF PROCEEDS OF JUDGMENT HEARING DATE, IF ANY: DEPT.: FOR MINOR OR PERSON WITH A DISABILITY 1. Hearing w a. [__] 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: '-n 2. Petitioner (name or pseudonym*): John Mohammad Khan >< is the (check all relationships or representative capacities that apply): [X] parent [ ] guardian ad litem* TX] 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): Omar Alexander Khan 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”)): Habiba Hashimi, THE COURT FINDS 5. X7 [ 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. [X] The claimant's consent to this order is not required because the claimant is a minor, a conservatee, or a person who lacks o the order within the meaning of Probate Code section 812. Page 1 of 4 J i : SuccalCaueiof Caioma MC-351 [Rev. January \ + >, “@BDER/APPROVING 1, 2021 O/b COMPROMISE OF CLAIM OR ACTION DISPOSITION OF PROCEEDS OF JUDGMENT Probate Code, § 500, 9606- 3613 Cal. Rules of Court, rules.aggi’?:,c;gge /L FOR MINOR OR PERSON WITH A DISABILITY MC-351 CASE NAME: In the Matter of Amaira Aioko Daniels 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: $ 60.000 . 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: $ 20.000 payable to (specify): Jacoby and Meyers Attorneys LLP (2) [X] Reimbursement for medical and all other expenses paid by the petitioner or the petitioner's attorney in the total amount of: $ 1.123.20 * (3) [X] Medical, hospital, ambulance, nursing, and other similar expenses payable directly to providers as follows, in the total amount of: $ 16.015.09 = (a) Payee (name): U.C. Davis Medical Center (i) address: P.O. Box 743481 Los Angeles CA 90074-3481 (ii) Amount: $ 8.056.16 (b) Payee (name): Eauian/Kaiser (i) address: 9390 Bunsen Parkway Lousville, KY 40220 (ii) Amount: $ 7.958.93 [ 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). (6) [X] Total allowance for fees and expenses from the settlement or judgment: $ 37.138.29 MC-351 [Rev. January 1, 2021] Page 2 of 4 ORDER APPROVING COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-351 CASE NAME: In the Matter of Amaira Aioko Daniels 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: $ 22.861.71 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) X By the following method(s) (describe each method, including the amount to be disbursed by each): Check payable to Jacoby and Meyers Attorneys LLP in the amount of $37,138.29 for Legal Fees, Medical Payments and Costs. A check for the remaining balance of $22,861.70, which will be used to purchase a structured settlement annuity, per Attachment 8b(2). X Continued on Attachment 8b(2). (3) [_] fmoney 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 PRESSIIIS OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-351 CASE NAME: In the Matter of Amaira Aioko Daniels 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) [__] The blocked account or accounts belong to a minor, who was born on (date): 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 depository, 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: $ X 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 NGB [Row Janaley 2020 ORDER APPROVING COMPROMISE OF CLAIM OR ACTION Pegeiots OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ATTACHMENT 8b(2) To MC-351 ¢ ATTACHMENT 18b(3) TO MC-350 e ATTACHMENT 19b(3) To MC-350EX Terms and Conditions of the Annuity for Omar Khan The Court so orders that $23,528.38 be paid by Defendant and/or its Insurer (“Payor”) to purchase a structured settlement annuity, in which MetLife Assignment Company (€ Assignee) will provide for the following Periodic Payments to be made by Metropolitan Tower Life Insurance Company (€ Annuity Issuer), an A+ (Superior) by A.M. Best. The details of the periodic payments of which will be set forth below. All sums constitute damages on account of personal physical injuries arising from an occurrence within the meaning of Section 104(a)(2) of the Internal Revenue Code. The periodic payment schedule is as follows: PAYEE: OMAR KHAN Lump Sum Payments $25,418.01 guaranteed lump sum payment at age 18 on 09/05/2027 FUNDING INSTRUCTIONS: Check Amount: $23,528.38 Check Payable To: METLIFE ASSIGNMENT COMPANY, INC. Tax ID#: 38-4035918 Send Check To: Tory Owens Structured Settlements 4712 Admiralty Way, Suite 434 Marina Del Rey, CA 90292 The future periodic payment amounts outlined herein are guaranteed based upon a projected annuity purchase date of 04/26/2024. Interest rates are volatile, and the above periodic payments may vary until locked in, which is a commitment to purchase; therefore, IF. THE RATE IS NOT LOCKED IN OR LATE FUNDING OCCURS IT MAY REQUIRE REVISION OF THE ABOVE PERIODIC PAYMENTS. Furthermore, any delay in funding the annuity may result in a delay of the payment dates or change in payment amounts. Any revisions to the periodic payments shall be recorded in the settlement agreement and release or the Addendum to the Settlement Agreement and Release, and/or qualified assignment document and annuity contract without the need of obtaining an amended Petition/Court Order/Infants Compromise Order. The Assignee and Annuity Owner are expressly authorized to make any date adjustments if there is a funding delay and reflect such date changes in the annuity contract and the qualified assignment agreement. Payee acknowledges and agrees that the Defendant(s) and/or the PAYOR shall make a "qualified assignment"”, within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, of the Defendant's and/or the PAYOR's liability to make the Periodic Payments required herein. Any such assignment, shall be accepted by the Payee without right of rejection and shall completely release and discharge the Defendant(s) and the PAYOR from such obligations hereunder as are assigned MetLife Assignment Company ("Assignee"). The Payee recognizes that, in the event of such an assignment, the Assignee shall be the sole obligor with respect to the Periodic Payments assigned, and that all other releases that pertain to the liability of the Defendant(s) and the PAYOR shall thereupon become final, irrevocable and absolute. Page 1 of 2 If the liability to make the periodic payments is assigned by way of a “qualified assignment.” A) Periodic payments from the Assignee cannot be accelerated, deferred, increased or decreased by Payee; B) The periodic payments from the Assignee will be fixed and determinable and may not be varied by any party; Q) The Assignee does not provide to the Payee rights against the Assignee greater than those of a general creditor; D) The Assignee’s obligation for payment of the periodic payments is no greater than the obligation of the person or entity originally liable (whether by suit or agreement) for payment and from whom the obligation was assigned. The sole obligor of the Periodic payments, whether it is the Defendant(s), the PAYOR, and/or the Assignee, reserves the right to fund the liability to make the Periodic Payments by purchasing an annuity through Metropolitan Tower Life Insurance Company ("Annuity Issuer"). The Defendant(s), the PAYOR, or in the event of an assignment the Assignee, shall be the sole owner of the annuity and have all rights in it. Said owner of the annuity may have Metropolitan Tower Life Insurance Company mail payments direct to the Payee. Payee shall be responsible for maintaining a current mailing address for Payee with Metropolitan Tower Life Insurance Company The obligation of the Defendant(s), the PAYOR, or in the event of an assignment, the obligation of its Assignee, to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment as stated herein to the designated address of the Payee. If the Payee or Beneficiary notifies the Assignee that any such check or electronic funds transfer was not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, shall have the Annuity Issuer process a replacement payment. Any payments to be made after the death of any Payee pursuant to the terms of this Agreement shall be made to such person or entity as shall be designated in writing by Claimant, upon reaching the age of majority, to the Insurer's Assignee. If no person or entity is so designated by Claimant, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. No such designation, nor any revocation thereof, shall be effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer's Assignee before such payments are made. Page 2 of 2 RECE CiVIL DRIOPVEDB0 HHMAR 25 PM 3: g