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sIGINA MC-360 L
ATTORNEY OR PARTY WITHOUT ATTORNEY (Namo, State Bernumber, and address}: FOR COURT
USE ONLY
Nathaniel M. Leeds [SBN: 246138], Callaway & Wolf
| 150 Post Street, Suite 600
San Francisco, CA 94108
TELEPHONE NO.: (415) 541-0300 FAXNO, (Optonay: (415) 777-6262 [= l L E D
E-MAIL ADDRESS (Optonap: nathaniel@callawayandwolf.com
‘ATTORNEY
FOR (Namo): Ambria Mabrey, Olivia Bennett, and Allena Mabrey
FEB 02 2016
‘SUPERIOR COURT OF CALIFORNIA, COUNTY OF FRESNO FRESNO SUPERIOR COURT
street aporéss: 1130 O Street “Mcecaoieas By.
MAILING ACDRESS: DEPUTY
cary nD ap cone: Fresno 93721-2220 Paton to Compromise Clalm of Minor
il | it il il
BRANCH NAME: '
(CASE NAME: CASE NUMBER:
Ambria Mabrey
et al. vs. Arle Ann Abbott
et al. 14CECGO1585
HEARING DATE:
PETITION TO APPROVE: [—] COMPROMISE OF DISPUTED CLAIM
[2] COMPROMISE OF PENDING ACTION March 16, 2016
([) DISPOSITION OF PROCEEDS OF JUDGMENT DEPT: 402 Time: 3:30 PM
(TZ) minor [_] Person
With a Disability
NOTICE TO PETITIONERS:
Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim ofa minor,
(2) the compromise ofa pending action or proceeding in which a minor or a person with a disability (including a conservatee) Is a
party, or (3) the disposition of the proceeds of a judgment fora minor
or person with a disability. (See Code Civ. Proc., § 372; Prob.
Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or
examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment,
and hospitalization. The court may consider on an expedited basis withouta hearing requests for approval of the compromises of
certain claims and actions or the disposition of the proceeds of certain judgments, If your claim, action, or judgment qualifies for
expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule
7,950.5.
4. Patitioner (name): James Bennett
2 Claimant (name): Ambria Mabrey, Olivia Bennett and Allena Mabrey
— filing jointly for approval of joint settlement and joint trust.
a. Address: 2386 North Wapoma Avenue, Fresno, CA 93722
b, Date
of birth; See attachment
2b Age: d. Sex: e. (7) Minor £7) Person
with a disability
3. Relationship Petitioner's relationship to the claimant (check aif applicable boxes):
a. C2) Parent
b. LZ) Guardian
ad item
g. £1 other relationship (specify) BY FAX
¢. Guardian
d. Conservator
{71 Disabled adutt claimantis a petitioner. (See instructions
for items 3e and 3f below.)
f. [) Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f.
-
(if you checkeditem 3¢ or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate
Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not
have & conservator of the estate may petition or consent to a petition. See Probate Code section 3613.)
Nature of claim The claim of the minor or adult person with a disability:
a CI Has not been filed in an action or proceeding. (Complete items 5-23.)
b. [21 1s the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
Name of court: Fresno County Superior Court
Case no.: 4CECG01585 Trial date; 09/26/16 (Complete items 5-23.)
Page
1 of 10
Altemativa|
Adopted tor PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ‘Coda ot CW Procadura,
§ 372 et 609:
Judital Counc § 9500 et seq:
Rev. January 1,2041) OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF (Cal Ruies of Court, nutas 3.
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 7.101, 7.950, 7.851
ew .couts.ca.gov
(Miscellaneous)
MC-350
CASE NAME:
|Ambria Mabrey et al. vs. Aria Ann Abbott et al. 14CECG01565
4, Nature of claim The claim of the minor or adult person with a disability:
c. [1] Is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against
the defendants named below in the total amount (exclusive of interest and costs) of (specify below):
$
Defendants (names)
. [) 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. [21 tncldentor accident The incident or accident occurred as follows:
a, Date and time: Merch 14, 2013
b. Place: University Oncology Center, 2335 E. Kashian Lane, Suite 301, Fresno, CA 93701
a Persons involved (names): Decedent, Lisa Atvarez, Defendant, Arie Ann Abbott, and remaining named defendants.
[2 Continued on Attachment 5.
6. [7] Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe):
Plaintiffs allege that Arle Ann Abbott's negligent access to decedent Lisa Alvarez's intravenous port caused Lisa Alvarez's
death. Claimants are decedent Lisa Alvarez's surviving children. This petition is being filed jointly by all of the children for
approval of the settlement and placement of the funds in a joint trust.
(1 Continued on Attachment 6.
7. CZ) Injuries
‘The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Claimants fost their mother, Lisa Alvarez, who died as aresult of injuries suffered in the incident.
(2) Continued
on Attachment 7.
8, [7] Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
None/Not applicable. Claimants claim wrongful death arising out of the wrongful death of their mother, Lisa Alverez.
(1 Continued
on Attachment 8.
(MC-250 Rev. January 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page2ot10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
ellaneous)
e e
CASE NAME: CASE NUMBER:
FAmbria Mabrey
et al. vs. Arie Ann Abbott
et al. 14CECG01585
9, CZ] Extent of Injuries
and recovery (An original or a photocopy of all doctors’ reports containing a diagnosis of and prognosis
for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 9.
A new report Is not necessary so long as a previous report eccurately describes the claimant's current condition.)
a. [7] The claimant has recovered completaly from the effects of the injuries described in item 7, and there are no
permanent injuries.
b, [2] 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):
£1 Continued on Attachment Sb.
¢. [21 The claimant has not recovered completely fram the effects
of the injuries described in item 7, and the following injuries
from which the clalmant has not recovered are permanent (describe the permanent injuries):
Claimants did not suffer physical injuries. Claimants’ damages stem from the wrongful death of their mother. Atthough
those injuries are permanent, there Is no physical manifestation or treatment. Claimants did not witness the negligence
leading their mother’s death, and are not making a claim for the infliction
of emotional distress.
=) Continued on Attachment 8c.
10. [2] Petitioner has made a careful and diligent Inquiry and investigation to ascertain the facts relating to the incident or
t 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 fully understands that if the compromise proposed in this
petition Is approved by the court and is consummated, the claimant will be forever barred from seeking any further
recovery of compensation from the settling defendants named below even though the claimant's Injuries may In
the future appear to be more serious than they are now thought
to be.
11.2) Amount and terms of settiement
By way of settlement, the defendants named below have offered to pay the following sums to the claimant:
a. The total amount offered by all defendants named below is (specify): s [350,000.00
b. The defendants and amounts offered by each are as follows (specify):
Amounts
Central Califomia Faculty Medical Group, inc., d/b/a University Oncology Associates: $350,000.00
$
$
$
$
(2 Defendants and amounts offered continued on Attachment 11.
©. The terms of settlement are as follows (if the seftiement is to be paid in installments, both the total amount and the
present value of the settiement must be included):
$350,000 In a lump sum payment to the three surviving children, Ambria Mabrey, Olivia Bennett, and Allena Mabrey, and
to satisfy
the MediCal lien on proceeds recovered in the survivorship action brought on behaif of the estate of Lisa
Alvarez. Those monies are to be put in a joint trust on behalf of all three girls, as described in Exhibit 19. An executed
copy of the settlement releaseis attached hereto as Attachment 11.
[Z1 Continued
on Attachment 11
180-350 Rev. January 1, 2011} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago Sot td
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
e ®
‘CASE NAME: (CASE NUMBER:
-Ambria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585
12,7) Settlement payments to others
a. [7] No defendant named in item 4 tb 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.
6. By way of settlement, one or more 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 (specify): $
(2) Petitioner [_] isnot [—] is actaimant against the recovery of the claimant (other than for
reimbursement for expenses pald by petitioner and listed under Item 15).
(if you answered "is," explain in Atachment 12 the circumstances and the effect your claim has on the
ft of the claim describedin this petition.)
(3) Petitioner isnot L_] is a plaintitfin the same action with the claimant.
(if you answered “is,” explain in Attachment 12 the circumstances and the effect your claim and its disposition
has on the proposed compromise of the claim or action described in this petition.)
(4) ££) Petitioner would receive money under the proposed settlement.
(5) The settlement payments ai to be apportioned and distributed as follows:
aintiff
$
$
$
$
[) Additional plaintiffs or claimants and amounts are listed on Attachment 12.
(6) Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 12.
43. The claimant's medical expenses, including medical expenses pald by petitioner and Insurers, to be reimbursed from
proceeds of settlement or Judgment
a. Totals
$ 17,408.79
—
(1) Total medical expenses:
(2) Total outstanding medical expenses to be paid from the proceeds: $
(3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds: $
sC ESE
b, Medical expenses were paid and are to be reimbursed from proceeds as follows:
(1) [2] Paid by petitionerin the amount of;
(2) [) Pats by private health insuranceor a self-funded plan under:
(2) (1 An Employee Retirement Income Security
Act (ERISA) insured plan.
(>) [2] An ERISA self-funded plan.
(©) (7) ANon-ERISA insured plan.
(@) (1 ANon-ERISA self-funded plan.
{e) Amount paid by plan: $
(f) Amount of reimbursement
to the plan from proceeds of settlement or judgment:
() £2) No reimbursement is requested by the plan.
(i) [£] Reimbursement
is to be made to the plan and:
(A) [) There is a contractual reduction of $ ( )
(8) (1) There
is a negotiated reductionof $¢ )
(ce) No reduction
has been agreed to,
fora total reimbursement
to the plan in the amount of sc)
#20-380 (Rov. January 1, 2911) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page det 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
CY
N ~ 4
MC-350
(CASE NAME: CASE NUMBER:
FAmbria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585
13. The claimant's medical expenses, Including medical expenses pald by petitioner and insurers,
to be reimbursed from
proceeds of settiement or judgment
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(3) [£2] Paid by Medicarein the amount of: $
less the statutory reduction in the amount of: $ ( )
fora total reimbursement to Medicare in the amount of: sl]
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(3).)
(4) CZ) Paid by Medi-Cal
in the amount of $ 17,408.79
[|
(a) [£1] Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
and Institutions
Code section 14124.73. A capy of the notice and proof ofits delivery [—] is attached.
J was filed in this matter on (date):
(>) (2) Notice of this claim or action has not been given to the State Director of Health Care Services.
(Explain why notice has not been given in Attachment 13b(4).)
© 4 In full satisfaction of its flan rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $ [12,288.00
(Attach a copy of the final Medi-Caf demand letter or fetter agreement as Attachment 136(4).)
@ CI Petitioner
Is entitled to a reduction of the Medi-Cal lien under Walfare and Institutions Code
section 14124.76 and:
[1 1s filing a motion seeking a reduction of the tien concurrently with this petition.
(i) [] Requests that the court reserve jurisdiction over this issue.
The amount of the flen in dispute is: $
(5) (1 (a) There are one or more statutory or contractual liens of medical service providers for paymentof medical
expenses. The total amount claimed under these liens is: $ In full satisfaction
totaaumot
S$ L___
of their lien claims, the fienholders have agreed to accept the total sum of:
and certain ofher medical service providers befow.)
(Provide requested information on each lienholder
(b) The name of each medical service provider that fumished care and treatment to claimant and (1) has a lien for all
or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any;
and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows:
(® (A) Provider (name):
(B) Address:
(C) Amount charged:
(0) Amount paid (whether or not by insurance): a
(E) Negotiated reduction, if any:
©) paeeata be pad Won prossede of etioment or pxgmedt:§ ——
i) (A) Provider (name):
(B) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): 3 )
(©) Negotiated reduction, if any: )
(F) Amount to be pald from proceeds of settiement or judgment: 3
{1 Continued
on Attachment 13b(5). (Provide information about additional providers in the above format,
including providers paid or to be paid by petitioner for which reimbursement is requested in item 13b(1)
above. You may use form MC-350(A-13b(5)) for this purpose.)
MC-250 (Rev. Jonuary
1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago Sot 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
LN
Ne SY
(CASE NAME: CASE NUMBER:
—Ampbria Mabrey et al. vs. Arie Ann Abbott
et al, 14CECG01585
14, The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attomey or pald or Incurrad by petitionerto be relmbursed from proceeds of settlement
or,
a. Total amount of attomey’s fees for which court approval Is requested:
(if faes are requested, attach
as Attachment 14a, a dectaration from the attorney explaining the basis for the request, including
a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules
of Court. Respond
to item 18a(2)
on page 7 and
attach a copy of any wnitten attomey fee agreement as Attachment 182.)
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 out of claimant's share of the proceeds of the settlement
or judgment:
Callaway
& Wolf case costs. See Attachment
14b. $ 15,452.74
Myers Urbatsch
case costs $85.00
(1
15. Reimbursement
Continues on Attachment 44b.
of expenses pald by petitioner
ro s ET]
a, {7 Petitioner has pald noneof the clalmant's expenses listed in items 13 and 14 for which reimbursement is requested.
b. [) Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which
reimbursement is requested.
(1) C1 Medical expenses listed in item 13: $
(2) Attomey’s fees included in the total fee amount shown in item 14a: $
(3) [_] Other expenses included in the total shown In item 14b:
Total: sc
(Attach proofs of the expenses incurred and payments made or obligations fo pay incurred, €.9., bills or invoices,
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
16. Net balance of proceeds for the claimant.
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
after payment of all requested fees and expenses is: [223.396.61
17. Summary
a Gross amount of proceeds of settlement or judgment for claimant: $ 350,000.00
b. Medical expenses to be paid from proceeds of settlement
or judgment $ 12,288.00
CG Attomey’s fees to be paid from proceeds of settlement or
judgment: $ 98,636.48
Expenses (other than medical) to be paid from proceeds.
of settlement or judgment: g 15,537.71
‘Total of fees and expenses to be paid fram proceeds of settlement or judgment
{add (b), (0), and (d}):
$ ( 126,664.19 )
Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (a) from (a)): $fe2ssa6e1
‘MC-I80[Rev. Jsnuary 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
Le WY
CASE NAME:
-Ambria Mabrey et al. vs. Arie Ann Abbott et al.
(CASE NUMBER
14CECG01585
“
18. Information about attomey representing or assisting petitioner
a. (1) [] Petitioner has not been represented or assisted by an attomey in preparing this petition or in any other way with
respect to the claim asserted. (Go fo item 19.)
(2) [2] Petitioner has been represented or assisted by an attomey in preparing this petition or with respect to the claim
|. Petitioner
and the attomey [__] donot [7] do have an agreement for services provided in
connection with the claim giving rise to this petition. (if you answered “do,” attach a copy of the agreement as
Attachment 182, and complete items 18b.-18f.)
The attomey who has represented or assisted petitioner Is (name): Nathaniel Leeds
(1) State Bar number. 246138
(2) Law fim: Callaway and Wolf
(3) Address:
150 Post Street, Suite 600, San Francisco, CA 94108
(4) Telephone number. (415) 541-0300
The attomey [7] hasnot [_] has received attomey’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,” identify the person
who paid the fees or other compensation, the amounts paid, and the dates of payment):
From whom (names) Dates
£1 Continued on Attachment 18c.
The attomey [77] didnot [] did become concemed with this matter, directly or indirectly, at the Instance of a party
against whom the claim is asserted or a party's insurance cartier. (if you answered “did,” explain the circumstances
in
Attachment 18d.)
The attomey [7] isnot [—] is representing or employed by any other party or any insurance carrer Involved in the
matter. (if you answered “is,” identify the party or carrier and explain the relationship in Attachment 16e.)
The attomey [Z] doesnot [_] does expect to receive attomey's fees or other compensation in addition to that
requested in this petition for services provided in connection with the claim giving rise to this petition. (If you answered "does,"
identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment):
From whom (names)
(1 Continued on Attachment 18f.
(MO-S80 (Rov. January 1, 2019) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page?
of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
oN
Ne } O
MC-350
TSE NAME: CASE NUMBER:
F-Ambria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585
19. Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds
of the settlement or Judgment be disbursed as follows:
a, (7) 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.:
ocos of the proceedsin money or other property will be paid or deliveredto
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),
ac Patitioner 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) with one or more financial institutions
In this state or with a trust
company, subjactto withdrawal only as authorized by 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).
eC Petitioner proposes that all ora 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
ail that apply):
® Cs will be deposited
in Insured accounts
in one or more financial
institutions in this state from which no withdrawals can be made without a court order.
The name, branch, and address of each depository are specified in Attachment 19a(3).
o Cs will be invasted in a single-premium deferred annuity subject to
withdrawal only on order of the court. The terms and conditions of the annuity are specified in
Attachment 198(3).
© C$ will 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).
®@CIs will be transferred
to the trustee of a trust that Is elther created by or
approved of in the order approving the settlement or the judgment given or to be given for the
minor. This trust is revocable when the minor attains the age of 18 years and contains all other
terms and conditions determined to be necessary by the court to protect the minor's interests. The
19a(3).
in Attachmented
terms of the proposed trust and the property to be transferred are specifi
(1A copyof the (proposed) Judgment is attached as Attachment 4c.
es will be transferred to the trustee of a special needs trust under
Probate
Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a
disability. The terms of the proposed special needs trust and the property to be transferred are
specified in Attachment 19a(3).
‘MC-350[Rev. January 1, 2019] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago Bot 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
cy as
\ J
CASE NAME; ‘CASE NUMBER:
-Ambria Mabrey et al. vs. Arie Ann Abbott
et al. 14CECG01585
19. Disposition of balance of proceeds of settlement
or judgment (cont)
Petitioner requests that the balance of the proceeds
of the settlement or judgment be disbursed as follows:
b. (22) There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with adisability.
Pefitionar requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
(check
ai! thet epply):
(1) (£2) Aguardian of the estate of the minor or a conservator of the estate of the adult person with a disability
willbe appointed. $ of money and other property will be paid or delivered
to the person so appointed, The money or other property are specified in Attachment 19b(1).
@Cis ‘of money will be deposited in insured accounts in one or more financial
Institutions in this state, subject to withdrawal only upon the authorization of the court. The name,
branch, and address of each depository are specified In Attachment 19b(2).
aos of money will be invested in a single-premium deferred annuity, subject to
withdrawal only upon the authorization of the court. The tems and conditions of the annulty are specified
in Attachment 19b(3).
@Co$s will be paid or transferred to the trustee of a special needs trust under
Probate Code sections 3604 and 3611(c) for the benefit of the minor or the adult person with a disability.
‘The terms of the proposed special needs trust and the money or other property to be paid or transferred are
specified In Attachment 19b(4).
eis will be paid or delivered to a parent of the minor, upon the terns 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(5). (Value of minor's
entire estate, including the money or property to be delivared, must not exceed $5,000.)
6) $ will betransferredto a custodian for the benefit of the minor under the Califomia
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(6).
(7) (2) $223,335.81 will be transferred to the trustee of a trust that is either created by or
approved of in the order approving the settlement or the judgment given or to be given for the minor. This
trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions
determined to be necessary by the court fo protect the minor's interests. The terms of the proposed trust and
the money or other property to be transferred are specified in Attachment 19b{7).
EE) A copy of the (proposed) judgment is attached as Attachment 4c.
eos of money will be held on such conditions as the court in its discretion determines
is In the best interest of the minor or the adult person with a disability. The proposed conditions are specified
‘on Attachment 19b(8). (Value must not exceed $20,000.)
ols of property other than money will be held on such conditions
as the court in its
discretion determines Is in the best interest of the minor or the adult person with a disability. The proposed
conditions and the property are specified in Attachment 19b(9).
(oC $ will 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).
anc $ will be paid or transferred to the adult person with a disability. The money or other
property is specified in Attachment 19b(11).
(=) Continued on Attachment 19.
MC-350 Rev. January 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago dot 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
“~
NA eH
Ee ama
20. 2) Statutory ttens for epectal neods trust
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sIGINA MC-360 L ATTORNEY OR PARTY WITHOUT ATTORNEY (Namo, State Bernumber, and address}: FOR COURT USE ONLY Nathaniel M. Leeds [SBN: 246138], Callaway & Wolf | 150 Post Street, Suite 600 San Francisco, CA 94108 TELEPHONE NO.: (415) 541-0300 FAXNO, (Optonay: (415) 777-6262 [= l L E D E-MAIL ADDRESS (Optonap: nathaniel@callawayandwolf.com ‘ATTORNEY FOR (Namo): Ambria Mabrey, Olivia Bennett, and Allena Mabrey FEB 02 2016 ‘SUPERIOR COURT OF CALIFORNIA, COUNTY OF FRESNO FRESNO SUPERIOR COURT street aporéss: 1130 O Street “Mcecaoieas By. MAILING ACDRESS: DEPUTY cary nD ap cone: Fresno 93721-2220 Paton to Compromise Clalm of Minor il | it il il BRANCH NAME: ' (CASE NAME: CASE NUMBER: Ambria Mabrey et al. vs. Arle Ann Abbott et al. 14CECGO1585 HEARING DATE: PETITION TO APPROVE: [—] COMPROMISE OF DISPUTED CLAIM [2] COMPROMISE OF PENDING ACTION March 16, 2016 ([) DISPOSITION OF PROCEEDS OF JUDGMENT DEPT: 402 Time: 3:30 PM (TZ) minor [_] Person With a Disability NOTICE TO PETITIONERS: Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim ofa minor, (2) the compromise ofa pending action or proceeding in which a minor or a person with a disability (including a conservatee) Is a party, or (3) the disposition of the proceeds of a judgment fora minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court may consider on an expedited basis withouta hearing requests for approval of the compromises of certain claims and actions or the disposition of the proceeds of certain judgments, If your claim, action, or judgment qualifies for expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule 7,950.5. 4. Patitioner (name): James Bennett 2 Claimant (name): Ambria Mabrey, Olivia Bennett and Allena Mabrey — filing jointly for approval of joint settlement and joint trust. a. Address: 2386 North Wapoma Avenue, Fresno, CA 93722 b, Date of birth; See attachment 2b Age: d. Sex: e. (7) Minor £7) Person with a disability 3. Relationship Petitioner's relationship to the claimant (check aif applicable boxes): a. C2) Parent b. LZ) Guardian ad item g. £1 other relationship (specify) BY FAX ¢. Guardian d. Conservator {71 Disabled adutt claimantis a petitioner. (See instructions for items 3e and 3f below.) f. [) Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f. - (if you checkeditem 3¢ or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not have & conservator of the estate may petition or consent to a petition. See Probate Code section 3613.) Nature of claim The claim of the minor or adult person with a disability: a CI Has not been filed in an action or proceeding. (Complete items 5-23.) b. [21 1s the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim. Name of court: Fresno County Superior Court Case no.: 4CECG01585 Trial date; 09/26/16 (Complete items 5-23.) Page 1 of 10 Altemativa| Adopted tor PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ‘Coda ot CW Procadura, § 372 et 609: Judital Counc § 9500 et seq: Rev. January 1,2041) OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF (Cal Ruies of Court, nutas 3. JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 7.101, 7.950, 7.851 ew .couts.ca.gov (Miscellaneous) MC-350 CASE NAME: |Ambria Mabrey et al. vs. Aria Ann Abbott et al. 14CECG01565 4, Nature of claim The claim of the minor or adult person with a disability: c. [1] Is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against the defendants named below in the total amount (exclusive of interest and costs) of (specify below): $ Defendants (names) . [) 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. [21 tncldentor accident The incident or accident occurred as follows: a, Date and time: Merch 14, 2013 b. Place: University Oncology Center, 2335 E. Kashian Lane, Suite 301, Fresno, CA 93701 a Persons involved (names): Decedent, Lisa Atvarez, Defendant, Arie Ann Abbott, and remaining named defendants. [2 Continued on Attachment 5. 6. [7] Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe): Plaintiffs allege that Arle Ann Abbott's negligent access to decedent Lisa Alvarez's intravenous port caused Lisa Alvarez's death. Claimants are decedent Lisa Alvarez's surviving children. This petition is being filed jointly by all of the children for approval of the settlement and placement of the funds in a joint trust. (1 Continued on Attachment 6. 7. CZ) Injuries ‘The following injuries were sustained by the claimant as a result of the incident or accident (describe): Claimants fost their mother, Lisa Alvarez, who died as aresult of injuries suffered in the incident. (2) Continued on Attachment 7. 8, [7] Treatment The claimant received the following care and treatment for the injuries described in item 7 (describe): None/Not applicable. Claimants claim wrongful death arising out of the wrongful death of their mother, Lisa Alverez. (1 Continued on Attachment 8. (MC-250 Rev. January 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page2ot10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ellaneous) e e CASE NAME: CASE NUMBER: FAmbria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585 9, CZ] Extent of Injuries and recovery (An original or a photocopy of all doctors’ reports containing a diagnosis of and prognosis for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 9. A new report Is not necessary so long as a previous report eccurately describes the claimant's current condition.) a. [7] The claimant has recovered completaly from the effects of the injuries described in item 7, and there are no permanent injuries. b, [2] 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): £1 Continued on Attachment Sb. ¢. [21 The claimant has not recovered completely fram the effects of the injuries described in item 7, and the following injuries from which the clalmant has not recovered are permanent (describe the permanent injuries): Claimants did not suffer physical injuries. Claimants’ damages stem from the wrongful death of their mother. Atthough those injuries are permanent, there Is no physical manifestation or treatment. Claimants did not witness the negligence leading their mother’s death, and are not making a claim for the infliction of emotional distress. =) Continued on Attachment 8c. 10. [2] Petitioner has made a careful and diligent Inquiry and investigation to ascertain the facts relating to the incident or t 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 fully understands that if the compromise proposed in this petition Is approved by the court and is consummated, the claimant will be forever barred from seeking any further recovery of compensation from the settling defendants named below even though the claimant's Injuries may In the future appear to be more serious than they are now thought to be. 11.2) Amount and terms of settiement By way of settlement, the defendants named below have offered to pay the following sums to the claimant: a. The total amount offered by all defendants named below is (specify): s [350,000.00 b. The defendants and amounts offered by each are as follows (specify): Amounts Central Califomia Faculty Medical Group, inc., d/b/a University Oncology Associates: $350,000.00 $ $ $ $ (2 Defendants and amounts offered continued on Attachment 11. ©. The terms of settlement are as follows (if the seftiement is to be paid in installments, both the total amount and the present value of the settiement must be included): $350,000 In a lump sum payment to the three surviving children, Ambria Mabrey, Olivia Bennett, and Allena Mabrey, and to satisfy the MediCal lien on proceeds recovered in the survivorship action brought on behaif of the estate of Lisa Alvarez. Those monies are to be put in a joint trust on behalf of all three girls, as described in Exhibit 19. An executed copy of the settlement releaseis attached hereto as Attachment 11. [Z1 Continued on Attachment 11 180-350 Rev. January 1, 2011} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago Sot td OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) e ® ‘CASE NAME: (CASE NUMBER: -Ambria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585 12,7) Settlement payments to others a. [7] No defendant named in item 4 tb 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. 6. By way of settlement, one or more 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 (specify): $ (2) Petitioner [_] isnot [—] is actaimant against the recovery of the claimant (other than for reimbursement for expenses pald by petitioner and listed under Item 15). (if you answered "is," explain in Atachment 12 the circumstances and the effect your claim has on the ft of the claim describedin this petition.) (3) Petitioner isnot L_] is a plaintitfin the same action with the claimant. (if you answered “is,” explain in Attachment 12 the circumstances and the effect your claim and its disposition has on the proposed compromise of the claim or action described in this petition.) (4) ££) Petitioner would receive money under the proposed settlement. (5) The settlement payments ai to be apportioned and distributed as follows: aintiff $ $ $ $ [) Additional plaintiffs or claimants and amounts are listed on Attachment 12. (6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 12. 43. The claimant's medical expenses, including medical expenses pald by petitioner and Insurers, to be reimbursed from proceeds of settlement or Judgment a. Totals $ 17,408.79 — (1) Total medical expenses: (2) Total outstanding medical expenses to be paid from the proceeds: $ (3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds: $ sC ESE b, Medical expenses were paid and are to be reimbursed from proceeds as follows: (1) [2] Paid by petitionerin the amount of; (2) [) Pats by private health insuranceor a self-funded plan under: (2) (1 An Employee Retirement Income Security Act (ERISA) insured plan. (>) [2] An ERISA self-funded plan. (©) (7) ANon-ERISA insured plan. (@) (1 ANon-ERISA self-funded plan. {e) Amount paid by plan: $ (f) Amount of reimbursement to the plan from proceeds of settlement or judgment: () £2) No reimbursement is requested by the plan. (i) [£] Reimbursement is to be made to the plan and: (A) [) There is a contractual reduction of $ ( ) (8) (1) There is a negotiated reductionof $¢ ) (ce) No reduction has been agreed to, fora total reimbursement to the plan in the amount of sc) #20-380 (Rov. January 1, 2911) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page det 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) CY N ~ 4 MC-350 (CASE NAME: CASE NUMBER: FAmbria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585 13. The claimant's medical expenses, Including medical expenses pald by petitioner and insurers, to be reimbursed from proceeds of settiement or judgment b. Medical expenses were paid and are to be reimbursed from proceeds as follows: (3) [£2] Paid by Medicarein the amount of: $ less the statutory reduction in the amount of: $ ( ) fora total reimbursement to Medicare in the amount of: sl] (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(3).) (4) CZ) Paid by Medi-Cal in the amount of $ 17,408.79 [| (a) [£1] Notice of this claim or action has been given to the State Director of Health Care Services under Welfare and Institutions Code section 14124.73. A capy of the notice and proof ofits delivery [—] is attached. J was filed in this matter on (date): (>) (2) Notice of this claim or action has not been given to the State Director of Health Care Services. (Explain why notice has not been given in Attachment 13b(4).) © 4 In full satisfaction of its flan rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ [12,288.00 (Attach a copy of the final Medi-Caf demand letter or fetter agreement as Attachment 136(4).) @ CI Petitioner Is entitled to a reduction of the Medi-Cal lien under Walfare and Institutions Code section 14124.76 and: [1 1s filing a motion seeking a reduction of the tien concurrently with this petition. (i) [] Requests that the court reserve jurisdiction over this issue. The amount of the flen in dispute is: $ (5) (1 (a) There are one or more statutory or contractual liens of medical service providers for paymentof medical expenses. The total amount claimed under these liens is: $ In full satisfaction totaaumot S$ L___ of their lien claims, the fienholders have agreed to accept the total sum of: and certain ofher medical service providers befow.) (Provide requested information on each lienholder (b) The name of each medical service provider that fumished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any; and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows: (® (A) Provider (name): (B) Address: (C) Amount charged: (0) Amount paid (whether or not by insurance): a (E) Negotiated reduction, if any: ©) paeeata be pad Won prossede of etioment or pxgmedt:§ —— i) (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): 3 ) (©) Negotiated reduction, if any: ) (F) Amount to be pald from proceeds of settiement or judgment: 3 {1 Continued on Attachment 13b(5). (Provide information about additional providers in the above format, including providers paid or to be paid by petitioner for which reimbursement is requested in item 13b(1) above. You may use form MC-350(A-13b(5)) for this purpose.) MC-250 (Rev. Jonuary 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago Sot 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) LN Ne SY (CASE NAME: CASE NUMBER: —Ampbria Mabrey et al. vs. Arie Ann Abbott et al, 14CECG01585 14, The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by claimant's attomey or pald or Incurrad by petitionerto be relmbursed from proceeds of settlement or, a. Total amount of attomey’s fees for which court approval Is requested: (if faes are requested, attach as Attachment 14a, a dectaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Respond to item 18a(2) on page 7 and attach a copy of any wnitten attomey fee agreement as Attachment 182.) 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 out of claimant's share of the proceeds of the settlement or judgment: Callaway & Wolf case costs. See Attachment 14b. $ 15,452.74 Myers Urbatsch case costs $85.00 (1 15. Reimbursement Continues on Attachment 44b. of expenses pald by petitioner ro s ET] a, {7 Petitioner has pald noneof the clalmant's expenses listed in items 13 and 14 for which reimbursement is requested. b. [) Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which reimbursement is requested. (1) C1 Medical expenses listed in item 13: $ (2) Attomey’s fees included in the total fee amount shown in item 14a: $ (3) [_] Other expenses included in the total shown In item 14b: Total: sc (Attach proofs of the expenses incurred and payments made or obligations fo pay incurred, €.9., bills or invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) 16. Net balance of proceeds for the claimant. The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment of all requested fees and expenses is: [223.396.61 17. Summary a Gross amount of proceeds of settlement or judgment for claimant: $ 350,000.00 b. Medical expenses to be paid from proceeds of settlement or judgment $ 12,288.00 CG Attomey’s fees to be paid from proceeds of settlement or judgment: $ 98,636.48 Expenses (other than medical) to be paid from proceeds. of settlement or judgment: g 15,537.71 ‘Total of fees and expenses to be paid fram proceeds of settlement or judgment {add (b), (0), and (d}): $ ( 126,664.19 ) Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (a) from (a)): $fe2ssa6e1 ‘MC-I80[Rev. Jsnuary 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Le WY CASE NAME: -Ambria Mabrey et al. vs. Arie Ann Abbott et al. (CASE NUMBER 14CECG01585 “ 18. Information about attomey representing or assisting petitioner a. (1) [] Petitioner has not been represented or assisted by an attomey in preparing this petition or in any other way with respect to the claim asserted. (Go fo item 19.) (2) [2] Petitioner has been represented or assisted by an attomey in preparing this petition or with respect to the claim |. Petitioner and the attomey [__] donot [7] do have an agreement for services provided in connection with the claim giving rise to this petition. (if you answered “do,” attach a copy of the agreement as Attachment 182, and complete items 18b.-18f.) The attomey who has represented or assisted petitioner Is (name): Nathaniel Leeds (1) State Bar number. 246138 (2) Law fim: Callaway and Wolf (3) Address: 150 Post Street, Suite 600, San Francisco, CA 94108 (4) Telephone number. (415) 541-0300 The attomey [7] hasnot [_] has received attomey’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,” identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment): From whom (names) Dates £1 Continued on Attachment 18c. The attomey [77] didnot [] did become concemed with this matter, directly or indirectly, at the Instance of a party against whom the claim is asserted or a party's insurance cartier. (if you answered “did,” explain the circumstances in Attachment 18d.) The attomey [7] isnot [—] is representing or employed by any other party or any insurance carrer Involved in the matter. (if you answered “is,” identify the party or carrier and explain the relationship in Attachment 16e.) The attomey [Z] doesnot [_] does expect to receive attomey's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition. (If you answered "does," identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment): From whom (names) (1 Continued on Attachment 18f. (MO-S80 (Rov. January 1, 2019) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page? of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) oN Ne } O MC-350 TSE NAME: CASE NUMBER: F-Ambria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585 19. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance of the proceeds of the settlement or Judgment be disbursed as follows: a, (7) 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.: ocos of the proceedsin money or other property will be paid or deliveredto 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), ac Patitioner 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) with one or more financial institutions In this state or with a trust company, subjactto withdrawal only as authorized by 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). eC Petitioner proposes that all ora 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 ail that apply): ® Cs will be deposited in Insured accounts in one or more financial institutions in this state from which no withdrawals can be made without a court order. The name, branch, and address of each depository are specified in Attachment 19a(3). o Cs will be invasted in a single-premium deferred annuity subject to withdrawal only on order of the court. The terms and conditions of the annuity are specified in Attachment 198(3). © C$ will 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). ®@CIs will be transferred to the trustee of a trust that Is elther created by or approved of in the order approving the settlement or the judgment given or to be given for the minor. This trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The 19a(3). in Attachmented terms of the proposed trust and the property to be transferred are specifi (1A copyof the (proposed) Judgment is attached as Attachment 4c. es will be transferred to the trustee of a special needs trust under Probate Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the property to be transferred are specified in Attachment 19a(3). ‘MC-350[Rev. January 1, 2019] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago Bot 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) cy as \ J CASE NAME; ‘CASE NUMBER: -Ambria Mabrey et al. vs. Arie Ann Abbott et al. 14CECG01585 19. Disposition of balance of proceeds of settlement or judgment (cont) Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows: b. (22) There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with adisability. Pefitionar requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check ai! thet epply): (1) (£2) Aguardian of the estate of the minor or a conservator of the estate of the adult person with a disability willbe appointed. $ of money and other property will be paid or delivered to the person so appointed, The money or other property are specified in Attachment 19b(1). @Cis ‘of money will be deposited in insured accounts in one or more financial Institutions in this state, subject to withdrawal only upon the authorization of the court. The name, branch, and address of each depository are specified In Attachment 19b(2). aos of money will be invested in a single-premium deferred annuity, subject to withdrawal only upon the authorization of the court. The tems and conditions of the annulty are specified in Attachment 19b(3). @Co$s will be paid or transferred to the trustee of a special needs trust under Probate Code sections 3604 and 3611(c) for the benefit of the minor or the adult person with a disability. ‘The terms of the proposed special needs trust and the money or other property to be paid or transferred are specified In Attachment 19b(4). eis will be paid or delivered to a parent of the minor, upon the terns 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(5). (Value of minor's entire estate, including the money or property to be delivared, must not exceed $5,000.) 6) $ will betransferredto a custodian for the benefit of the minor under the Califomia 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(6). (7) (2) $223,335.81 will be transferred to the trustee of a trust that is either created by or approved of in the order approving the settlement or the judgment given or to be given for the minor. This trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions determined to be necessary by the court fo protect the minor's interests. The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 19b{7). EE) A copy of the (proposed) judgment is attached as Attachment 4c. eos of money will be held on such conditions as the court in its discretion determines is In the best interest of the minor or the adult person with a disability. The proposed conditions are specified ‘on Attachment 19b(8). (Value must not exceed $20,000.) ols of property other than money will be held on such conditions as the court in its discretion determines Is in the best interest of the minor or the adult person with a disability. The proposed conditions and the property are specified in Attachment 19b(9). (oC $ will 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). anc $ will be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 19b(11). (=) Continued on Attachment 19. MC-350 Rev. January 1, 2011) PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pago dot 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) “~ NA eH Ee ama 20. 2) Statutory ttens for epectal neods trust