Preview
MC-350
ATTORNEY ORPARTYIMTHOUTATTORNEv tNane Slat
Ba umoer a daddmss)
Adam Sorrells SBN 160226 FOR COURTUSE DAILY
Law Office of Adam Sorrells
60 Independence Circle, Suite 100
Chico, CA 95973
TcLEPHoNE No(530) 893-9900 FAXNO (Opia0 (530) 893-9901
E-MAILADDREss(DPlo esq27Ocomcast.net
i)
ATTDRNEY FDR(r™) Ambrosia Carter 9/8/2020
SUPERIOR COURT OF CALIFORNIA, COUNTY OF BUTTE
sTREETADoREss 1775 Concord Avenue
MAILING ADDRESS
Chico, CA 95928
clTY AND ZIP coDE
BRANOH NAMENorth Butte County Courthouse
CASE NAME CASE NUMBER
Carter, et al
v. Bassow, et al 20CV01472
HEARING DATE
PETITION TO APPROVE: ~v COMPROMISE OF DISPUTED CLAIIIII
COMPROI)IIISE OF PENDING ACTION September 23, 2020
Minor ~
DISPOSITION OF PROCEEDS OF JUDGMENT
Person With a Disability
NOTICE TO PETITIONERS:
DEPT Tl)A TIME9 00 a.m
Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor,
(2) the 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) the disposition of the proceeds of a judgment for a minor or person with a disability
(See Code Civ Proc., 5 372; Prob
Code, 5 3600 et seq.) You and the minor or disabled person must atlend 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 ments of the claim and the nature and extent of the injury, care, treatment,
and hospitalization. The court may consider on an expedited basis without a 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 lodgment quahfies for
expedited consideration and you want to request lt, you must use form MC-350EX for your request. See Cal
Rules of Court, rule
7.950 5
1, Petitioner (name); Jeremy Boch
2. Claimant (name) Ambrosia Caner
a Address: 212 W. 22nd Street, Chico, CA 95928
b. Date of birth: c Age d Sex e. M Minor H Person with a disabihty
3
a ~
Relationship Petitioner's
Parent
relationship to the claimant (check a((appkcab(e boxes)
g CH Other relationship (spemfy)Court ordered legal guardian
b
c ~
~y
C]
Guardian ad htem
Guardian
d
e ~ Conservator
Disabled adult claimant is a petitioner.
(See lns(ruclions for r(ems 3e and 3fbe(ow)
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f.
((f you checked item 3e or 3f, state facts on A((achmen( 3e or 3( showing that the claimant has capacity
under Probate
Code section 812 fo petiffon or consen( (o a pelrtlon
Qn(y an adult c(arman( who has sufficient capaci(y and who does not
have a conservator of the estate may petr((on or consen( lo a pe(i(ion
See Probate Code section 3613)
4.
a
b
~
Nature of claim
~
The claim of the minor or adult person with a disabihty:
Has not been filed in an action or proceeding.
(Comp(e(e items 5-23)
Is the sub)act of a pending action or proceedmg that will be compromised without a tnal on the merits of the claim
Name of court:
Case nor Trial date: (Comp(ele items 5-23.)
P g Iof10
F*frrt Adopted for
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Code of 0
P ocedure 5372
I
seq.
I
Aaemate Mandaton Use P oasis Code,5350 ~
teq
Judtoal CIot C If rn a OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF cal Rules ofca rt, r les 3138a,
MC.350 [Rev January 1. 2011)
7101 7 950,7951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY emvco dscago
(Miscellaneous)
MC-350
CASE NAME. CASE NUMBER
arter, et al
v. Bassow, et al. 20CV01472
4 Nature of claim The claim of the minor or adult person with a disabikty
c. ~v 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 be/ow):
& )33,333.33
Defendants (names)
Jackson Dallas Bassow
Daniel Castillo
Additional defendants listed on Attachment 4 ~ The judgment was filed on (date)J
(Attach a copy oflhe (proposed)judgment as Attachment 4c and comprete items 13-23)
5. ~V Incident or accident The inadent or accident occurred as follows:
a. Date and time; 03-14-20
b. Place SR-99, Unincorporated Butte County
c persons involved (names) V'«oria Nystrom (Decedent); Jackson Dallas Bassow (Defendant driver);
Daniel Castillo (Defendant owner); Marianna Castillo (Bassow's passenger)
6. ~r
~ Continued on Attachment 5
Nature of incident or accident
The facts, events, and arcumstances of the inadent or accident are (descnbe)
Ambrosia Carter is the daughter of decedent Victona Nystrom. On or around March 14, 2020 on Highway 99 in
unincorporated Butte County, CA, Defendant Bassow was negligent in the operation of Defendant Castillo's motor vehicle,
causing him to smash head-on into the vehicle which Ms
Victoria Nystrom was operatingMs Nystrom sustained fatal
injunes as a result
Continued on Attachment 6
7 ~v'njuries
The following injuries were sustained by the claimant as a result of the inadent or acadent (describe):
Wrongful death case.
8.~ Continued on Attachment 7.
Treatment
The claimant received the following care and treatment for the mjuries described7 (descnbe).
in item
N/A
Continued on Attachment 8
Jao arr
MC-350 IRe 12011I PETITION TO APPROVE CONIPROMISE OF DISPUTED CLAIM Pose 2 af 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
NIC-350
CASE NAME CASE NUMBER
arter, et at v. Bassow, et al 20CV01472
9 ~ Extent of injuries and recovery (An original ore photocopy of all doclors'reports containing a diagnosis of and prognosis
for the claimant's in)ones, and a report of the claimant's present condition, must be attached to (his peliiion as Affachmenl 9
a. ~ A new report is nol necessary so long as a previous report accurately descn'bes the claimant's cunenl condriion.)
The claimant has recovered completely from the effects of the iniunes described in item 7, and there are no
b, ~ permanent injuries.
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 (descnbe lhe remaining inrunes)i
N/A wrongfuldeath case
~ Continued on Attachment 9b
0 ~ The claimant has not recovered completely from the effects of the injuries descnbed in item 7, and the following injuries
from which the claimant has not recovered are permanent (descnbe the permanent in)uries)
N/A wrongfuldeath case
Continued on Attachment 9c.
10. ~y Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to 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 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. ~y Amount and terms of settlement
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 detendants named below is (specify): $ ~33,333.33
b. The defendants and amounts offered by each are as follows (spewfy)i
Defendants (namesl Amounts
Jackson Dallas Bassow 0
$
Daniel Castillo (By 21st Century Insurance)
$ 33,333 33
$
$
~
c.
Defendants and amounts offered continued on Attachment 11.
The terms of settlement
$
are as follows (if the sefflemenl is lo be paid in inslallmenls, bof)r the lola) amount and the
present va/ue of(he sefflemenl musf be included):
A lump sum payment of $ 10,000 00 on April 10, 2022
A lump sum payment of $ 22,747.98 on April 10, 2029
These payments have a present value of $ 29,845 67
— the amount Ambrosia Carter, a minor,
willreceive affer fees and
costs have been deducted.
~ Contmued on Attachment
Jenuen1,2011]
MC-350 iRe
11
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 3 o1 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME CASE NUMBER
arter, et el
v Bassow, et el 20CV01472
~Z Settlement payments to others
12
a. ~ 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 inlury.
b E7 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)
(2) Petitioner~y isnot ~
The total amount offered by all defendants to others (specify):
is
$ 100,000. 00
a claimant against the recovery of the claimant (other than for
reimbursement for expenses paid by petitioner and hated under item 15)
(If you answered "is, "explain in Attachment 12 the circumstances and fhe effect your claim has on the
(3) petitioner ~y is not~
proposed co~mromise of the c/aim described in Ibis petibon.j
is a plaintiff in the same action with the claimant.
(If you answered "is, " exp/ain in Attachment 12 the circumstances and the effect your claim and its disposition
(4) ~
has on the proposed compromise of the c/aim or aclion described in this pelilion.j
Petitioner would receive money under the proposed settlement
The settlement payments are to be apportioned and distnbuted as follows:
(5)
Other olaintiffs or claimants (names) Amounts
Kameron Carter 33,333 33
Daisy Boch
$ 33,333 34
$
$
C3 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.
13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
a. Totals
(1) Total medical expenses: $
(2) expenses to be paid from the proceeds:
Total outstanding medical
(3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds
$ I
b
(1) ~
Medical expenses were paid and are to be reimbursed from proceeds as follows
~ Paid by petitioner in the amount of. $ l0
(2)
(a) ~
Paid by pnvate health insurance or a self-funded plan under
~ An Employee Retirement Income Security Act (ERISA) insured plan.
(b)
(c)
(d)
~
~
An ERISA self-funded plan.
A Non-ERISA insured plan.
A Non-ERISA self-funded plan
(e) Amount paid by plan: $
(f)
(i)~
Amount of reimbursement to the plan from proceeds of settlement or judgment:
M
(ii)
No reimbursement is requested by the plan.
Reimbursement is to be made to the plan and:
(A) M There is a contractual reduction of $ (
(8) M There is a negotiated reduction of
$(
(C) M No reduction has been agreed to,
for a total reimbursement to the plan in the amount of Sl
MC-350IRev January 1,2011i PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 4 er 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Misceffaneous)
C-350
IIII
CASE NAME CASE NUMBER
arter, et al
v.Bassow, et al 20CV01472
13 The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
Medical expenses were paid and are to be reimbursed from proceeds as follows:
b
(3) ~ Paid by Medicare inthe amount of; $ N/A
less the statutory reduction in the amount of
$(
for a total reimbursement to Medicare in the amount of: $ 1
(4)~ (Attach a copy of the final Medicare demand letter or letter agreement as Altachment 135(3) )
Paid by Medi-Cal in the amount of
~ $ N/A
(a)
~
and Institutions Code section 14124.73 ~
Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
A copy of the notice and proof of its delivery is attached.
(b) ~ was filed in this matter on (dale)i
Notice of this claim or action has not been given to the State Director of Health Care Services.
(c) ~ (Explain why notice has nol been gwen m Attachment 13b(4) )
In full satisfaction of its ken rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $ 1
(d) ~ (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachmenl 13b(4) )
Petitioner is entitled to a reduction of the Medi-Cal ben under Welfare and Institutions Code
(i)~
section 14124 76 and
~
(ii)
Is filing a motion seeking a reduction of the hen concurrently with this petition.
Requests that the court reserve jurisdiction over this issue.
The amount of the lien in dispute is
(5) ~ (a)
$
There are one or more statutory or contractual liens of medical service providers for payment of medical
expenses. The total amount claimed under these liens is.
$ N/A In full satisfaction
of their lien claims, the lienholders have agreed to accept the total sum of:
$
(Provide requesfed information on each lienholder and certam other medical service providers below)
(b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all
or any part of the charges or (2) was paid (or will be pard 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
(i)(A) Provider (name)
(B) Address;
(C) Amount charged $
(D) Amount paid (whether or not by insurance) $ (
(E) Negotiated reduction, if any. $ (
(F) Amount to be paid from proceeds ofsettlementor)udgment. $
I
(ii)
(A) Provider (name)
(B) Address.
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): $ ( )
(E) Negotiated reduction, if any $ ( )
(F) Amount to be paid from proceeds of settlement or judgment:
$ j
C7 Continued on Attachment 13b(5). (Provide information about addiiional prowders in the above format,
mcluding providers pard or lo be paid by pebti oner for which reimbursement is requested in item 13b(1)
above you may use form MC-350(A-13b(5)) for this purpose.)
MC-350IRay January 1,2011I
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Paaa 5
ay 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous}
MC-350
CASE NAME 011SE NUMBER
arter, et al.
v, Bassow, et al. 20CV01472
14 The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement or judgment
a Total amount of attorney's fees for which court approval is requested $ j3,333 33
(if fees are requested, attach as Attachment 14a, a declaration from the a(torney explaining lhe basis for ihe request, including
a discussion of applicable factors listed in rule 7 955(b) of the Cal
Ru/es of Court Respond to item 18a(2) on page 7 and
attach a copy of any written attorney fee agreement as Attachment 18a.)
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:
Items Pavees (names l Amounts
$
Fees
Filing Butte County Superior Court $ 154 33
$
$
$
$
$
$
$
$
$
Continued on Attachment 14b. Tomt: 5 154 33
I
15. Reimbursement of expenses paid by petitioner
a.
b ~
Mv Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested
Petitioner has paid (or become obhgated to pay) the following total amounts of the claimant's expenses for which
(1)~
reimbursement is requested
~ Medical expenses listed in item 13 $
(2)
(3)~ Attorney's fees included in the total fee amount shown in item 14a.
Other expenses included in the total shown in item 14b:
Total:
$
$
$ j
(Attach proofs af the expenses incuned end peymenls made or obligations ta pay incuned, e.g, bills or invoices,
canceled checks, credit card statements, explanatians af benefits from insurers, etc.)
16. Net balance of proceeds for the claimant
The balance of the proceeds of the proposed settlement or)udgment remaining for the claimant
after payment of all requested fees and expenses is. 29,845 67
$j
17 Summary
a. Gross amount of proceeds of settlement or judgment for claimant. $ 33,333.33
b Medical expenses to be paid from proceeds of settlement
or judgment $ 0
c Attorney's fees to be paid from proceeds of settlement or
judgment: $ 3,333 33
d. Expenses (other than medical) to be paid from proceeds
of settlement or judgment "
$
e Total of fees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c), and (d)): $ ( 3,487.66
f. Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (e) fram (a)): $ j29,845.67
Jaa ary
MC-330 lRe 1, 20111
Payee oi10
PETITION TO APPROVE COIIIIPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME CASE NUMBER
arter, et al. V. Bassow, et al. 20CV01472
18.
a. (1) ~
Information about attorney representing or assisting petitioner
Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with
respect to the claim asserted. (Go lo item 19.)
(2) ~y
asserted ~
Petitioner has been represented or assisted by an attorney in prepanng this petition ar with respect to the claim
Petitioner and the attorney do not ~K do have an agreement for services provided in
(if you answered udo, " attach a capy of the agreement as
connection with the claim giving rise to this petition.
Attachment 18a, and complete items 18b.-18f)
b. The attorney who has represented or assisted petitioner is (name) Adam Sorrells
(1) state Bar number: 160226
(2) Law firm: Law Office of Adam Sorrells
(3) Address.
60 Independence Circle, Suite 100, Chico, CA 95973
(4) Telephone number (530) 893-9900
c The attorneY ~y has not ~ has received attorney's fees or other compensation in addition to that requested in this
petition for services provided in connection with the claim giving nse to this petition
(if you answered ahas,"identify the person
who paid the fees or other compensation, the amounts paid, and the dales of payment):
From whom lnamesl Amounts Dates
d
~ Continued on Attachment 18c.
The attorney ~K did not ~ did become concerned with this matter, directly or indirectly, at the instance of a party
against whom the claim is asserted ore party's insurance carrier
(lf you answered adld," exp/ain the circumstances in
Attachment 18d
e The attorney ~)
is not [Q is representing or employed by any other party or any insurance carrier involved in the
matter. (if you answered "is, " identify the party or earner and explain lhe relationship in Attachment 18e )
The attorney ~ does not ~P does expect to receive attorney's fees or other compensation in addition to that
requested in this petition for services provided in connection with the claim givmg nse to this petition. (if you answered "does,"
identify the person who will pay the fees or alber compensation, the amounts lo be paid, and the expected dates of payment):
From whom (names) Amounts Exaected dates
Daniel Castillo (21st Century Ins.) $ 3,333.33 TBD
Daniel Castillo (21st Century Ins.) $ 3,333.34 TBD
$
$
$
M Continued on Attachment 18f.
Januaa1,2011i
MC-3301R 0
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM 0 0 20110
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR IIIIINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME CASE NUMBER
arter, et el
v Bassow, et el. 20CV01472
19 Disposition of balance of proceeds of settlement or judgment
a. ~
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
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 noz
(1) [ j $ of the proceeds in money or other property will be paid or delivered to
the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money
(2) ~ or other property is specified in Attachment 19a(1)
Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disabihty
Petitioner requests authonty to deposit or invest
$ of the money or other
property to be paid or dehvered under 19a(1) with one or more financial institutions in this state or with a trust
company, subject to 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 speafied 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 authonty to deposit or transfer these proceeds as follows
(check all that apply):
(a) C3 $ 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)
(b) H $ will be invested in a single-premium deferred annuity subiect to
withdrawal only on order of the court
The terms and conditions of the annuity are specified in
(c) ~ Attachment 19a(3)
$ will be transferred to a custodian for the benefit of the minor under the
Cahfornia 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)
(d) %$approved will be transferred to the trustee of a trust that is either created by or
of in the order approwng the settlement or the judgment gwen or to be given for the
minor. This trust is revocable when the minor attains the age of 16 years and contains all other
terms and conditions determined to be necessary by the court to protect the minor's interests. The
(e) ~ ~
terms of the proposed trust and the properly to be transferred are specified in Attachment 19a(3)
$
A copy of the (proposed) ludgment is attached as Attachment 4c.
will be transferred to the trustee of a spemal needs trust under
Probate Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a
disabibty. The terms of the proposed speaal needs trust and the properly to be transferred are
spemfied in Attachment 19a(3).
MC.350 [Roy January 1, 3011] Pflaa 8 of 10
PETITION TO APPROVE COINPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME CASE NUMBER
arter, et el
v Bassow, et el 20CV01472
19. Disposition of balance of proceeds of settlement or judgment (cont )
Petitioner requests that the balance of the proceeds of the settlement orjudgment be disbursed as follows:
b. ~d 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 a/l thai apply).
(1) ~ be appointed
will
estate of the minor or a conservator of the estate of the adult person with a disability
A guardian of the
$ of money and other property will be paid or delivered
to the person so appointedThe money or other property are specified in Attachment 19b(1).
(2) H $ of money will be deposited in insured accounts in one or more
Preview
MC-350 ATTORNEY ORPARTYIMTHOUTATTORNEv tNane Slat Ba umoer a daddmss) Adam Sorrells SBN 160226 FOR COURTUSE DAILY Law Office of Adam Sorrells 60 Independence Circle, Suite 100 Chico, CA 95973 TcLEPHoNE No(530) 893-9900 FAXNO (Opia0 (530) 893-9901 E-MAILADDREss(DPlo esq27Ocomcast.net i) ATTDRNEY FDR(r™) Ambrosia Carter 9/8/2020 SUPERIOR COURT OF CALIFORNIA, COUNTY OF BUTTE sTREETADoREss 1775 Concord Avenue MAILING ADDRESS Chico, CA 95928 clTY AND ZIP coDE BRANOH NAMENorth Butte County Courthouse CASE NAME CASE NUMBER Carter, et al v. Bassow, et al 20CV01472 HEARING DATE PETITION TO APPROVE: ~v COMPROMISE OF DISPUTED CLAIIIII COMPROI)IIISE OF PENDING ACTION September 23, 2020 Minor ~ DISPOSITION OF PROCEEDS OF JUDGMENT Person With a Disability NOTICE TO PETITIONERS: DEPT Tl)A TIME9 00 a.m Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor, (2) the 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) the disposition of the proceeds of a judgment for a minor or person with a disability (See Code Civ Proc., 5 372; Prob Code, 5 3600 et seq.) You and the minor or disabled person must atlend 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 ments of the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court may consider on an expedited basis without a 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 lodgment quahfies for expedited consideration and you want to request lt, you must use form MC-350EX for your request. See Cal Rules of Court, rule 7.950 5 1, Petitioner (name); Jeremy Boch 2. Claimant (name) Ambrosia Caner a Address: 212 W. 22nd Street, Chico, CA 95928 b. Date of birth: c Age d Sex e. M Minor H Person with a disabihty 3 a ~ Relationship Petitioner's Parent relationship to the claimant (check a((appkcab(e boxes) g CH Other relationship (spemfy)Court ordered legal guardian b c ~ ~y C] Guardian ad htem Guardian d e ~ Conservator Disabled adult claimant is a petitioner. (See lns(ruclions for r(ems 3e and 3fbe(ow) Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f. ((f you checked item 3e or 3f, state facts on A((achmen( 3e or 3( showing that the claimant has capacity under Probate Code section 812 fo petiffon or consen( (o a pelrtlon Qn(y an adult c(arman( who has sufficient capaci(y and who does not have a conservator of the estate may petr((on or consen( lo a pe(i(ion See Probate Code section 3613) 4. a b ~ Nature of claim ~ The claim of the minor or adult person with a disabihty: Has not been filed in an action or proceeding. (Comp(e(e items 5-23) Is the sub)act of a pending action or proceedmg that will be compromised without a tnal on the merits of the claim Name of court: Case nor Trial date: (Comp(ele items 5-23.) P g Iof10 F*frrt Adopted for PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Code of 0 P ocedure 5372 I seq. I Aaemate Mandaton Use P oasis Code,5350 ~ teq Judtoal CIot C If rn a OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF cal Rules ofca rt, r les 3138a, MC.350 [Rev January 1. 2011) 7101 7 950,7951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY emvco dscago (Miscellaneous) MC-350 CASE NAME. CASE NUMBER arter, et al v. Bassow, et al. 20CV01472 4 Nature of claim The claim of the minor or adult person with a disabikty c. ~v 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 be/ow): & )33,333.33 Defendants (names) Jackson Dallas Bassow Daniel Castillo Additional defendants listed on Attachment 4 ~ The judgment was filed on (date)J (Attach a copy oflhe (proposed)judgment as Attachment 4c and comprete items 13-23) 5. ~V Incident or accident The inadent or accident occurred as follows: a. Date and time; 03-14-20 b. Place SR-99, Unincorporated Butte County c persons involved (names) V'«oria Nystrom (Decedent); Jackson Dallas Bassow (Defendant driver); Daniel Castillo (Defendant owner); Marianna Castillo (Bassow's passenger) 6. ~r ~ Continued on Attachment 5 Nature of incident or accident The facts, events, and arcumstances of the inadent or accident are (descnbe) Ambrosia Carter is the daughter of decedent Victona Nystrom. On or around March 14, 2020 on Highway 99 in unincorporated Butte County, CA, Defendant Bassow was negligent in the operation of Defendant Castillo's motor vehicle, causing him to smash head-on into the vehicle which Ms Victoria Nystrom was operatingMs Nystrom sustained fatal injunes as a result Continued on Attachment 6 7 ~v'njuries The following injuries were sustained by the claimant as a result of the inadent or acadent (describe): Wrongful death case. 8.~ Continued on Attachment 7. Treatment The claimant received the following care and treatment for the mjuries described7 (descnbe). in item N/A Continued on Attachment 8 Jao arr MC-350 IRe 12011I PETITION TO APPROVE CONIPROMISE OF DISPUTED CLAIM Pose 2 af 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) NIC-350 CASE NAME CASE NUMBER arter, et at v. Bassow, et al 20CV01472 9 ~ Extent of injuries and recovery (An original ore photocopy of all doclors'reports containing a diagnosis of and prognosis for the claimant's in)ones, and a report of the claimant's present condition, must be attached to (his peliiion as Affachmenl 9 a. ~ A new report is nol necessary so long as a previous report accurately descn'bes the claimant's cunenl condriion.) The claimant has recovered completely from the effects of the iniunes described in item 7, and there are no b, ~ permanent injuries. 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 (descnbe lhe remaining inrunes)i N/A wrongfuldeath case ~ Continued on Attachment 9b 0 ~ The claimant has not recovered completely from the effects of the injuries descnbed in item 7, and the following injuries from which the claimant has not recovered are permanent (descnbe the permanent in)uries) N/A wrongfuldeath case Continued on Attachment 9c. 10. ~y Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to 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 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. ~y Amount and terms of settlement 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 detendants named below is (specify): $ ~33,333.33 b. The defendants and amounts offered by each are as follows (spewfy)i Defendants (namesl Amounts Jackson Dallas Bassow 0 $ Daniel Castillo (By 21st Century Insurance) $ 33,333 33 $ $ ~ c. Defendants and amounts offered continued on Attachment 11. The terms of settlement $ are as follows (if the sefflemenl is lo be paid in inslallmenls, bof)r the lola) amount and the present va/ue of(he sefflemenl musf be included): A lump sum payment of $ 10,000 00 on April 10, 2022 A lump sum payment of $ 22,747.98 on April 10, 2029 These payments have a present value of $ 29,845 67 — the amount Ambrosia Carter, a minor, willreceive affer fees and costs have been deducted. ~ Contmued on Attachment Jenuen1,2011] MC-350 iRe 11 PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 3 o1 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME CASE NUMBER arter, et el v Bassow, et el 20CV01472 ~Z Settlement payments to others 12 a. ~ 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 inlury. b E7 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) (2) Petitioner~y isnot ~ The total amount offered by all defendants to others (specify): is $ 100,000. 00 a claimant against the recovery of the claimant (other than for reimbursement for expenses paid by petitioner and hated under item 15) (If you answered "is, "explain in Attachment 12 the circumstances and fhe effect your claim has on the (3) petitioner ~y is not~ proposed co~mromise of the c/aim described in Ibis petibon.j is a plaintiff in the same action with the claimant. (If you answered "is, " exp/ain in Attachment 12 the circumstances and the effect your claim and its disposition (4) ~ has on the proposed compromise of the c/aim or aclion described in this pelilion.j Petitioner would receive money under the proposed settlement The settlement payments are to be apportioned and distnbuted as follows: (5) Other olaintiffs or claimants (names) Amounts Kameron Carter 33,333 33 Daisy Boch $ 33,333 34 $ $ C3 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. 13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment a. Totals (1) Total medical expenses: $ (2) expenses to be paid from the proceeds: Total outstanding medical (3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds $ I b (1) ~ Medical expenses were paid and are to be reimbursed from proceeds as follows ~ Paid by petitioner in the amount of. $ l0 (2) (a) ~ Paid by pnvate health insurance or a self-funded plan under ~ An Employee Retirement Income Security Act (ERISA) insured plan. (b) (c) (d) ~ ~ An ERISA self-funded plan. A Non-ERISA insured plan. A Non-ERISA self-funded plan (e) Amount paid by plan: $ (f) (i)~ Amount of reimbursement to the plan from proceeds of settlement or judgment: M (ii) No reimbursement is requested by the plan. Reimbursement is to be made to the plan and: (A) M There is a contractual reduction of $ ( (8) M There is a negotiated reduction of $( (C) M No reduction has been agreed to, for a total reimbursement to the plan in the amount of Sl MC-350IRev January 1,2011i PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 4 er 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Misceffaneous) C-350 IIII CASE NAME CASE NUMBER arter, et al v.Bassow, et al 20CV01472 13 The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment Medical expenses were paid and are to be reimbursed from proceeds as follows: b (3) ~ Paid by Medicare inthe amount of; $ N/A less the statutory reduction in the amount of $( for a total reimbursement to Medicare in the amount of: $ 1 (4)~ (Attach a copy of the final Medicare demand letter or letter agreement as Altachment 135(3) ) Paid by Medi-Cal in the amount of ~ $ N/A (a) ~ and Institutions Code section 14124.73 ~ Notice of this claim or action has been given to the State Director of Health Care Services under Welfare A copy of the notice and proof of its delivery is attached. (b) ~ was filed in this matter on (dale)i Notice of this claim or action has not been given to the State Director of Health Care Services. (c) ~ (Explain why notice has nol been gwen m Attachment 13b(4) ) In full satisfaction of its ken rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ 1 (d) ~ (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachmenl 13b(4) ) Petitioner is entitled to a reduction of the Medi-Cal ben under Welfare and Institutions Code (i)~ section 14124 76 and ~ (ii) Is filing a motion seeking a reduction of the hen concurrently with this petition. Requests that the court reserve jurisdiction over this issue. The amount of the lien in dispute is (5) ~ (a) $ There are one or more statutory or contractual liens of medical service providers for payment of medical expenses. The total amount claimed under these liens is. $ N/A In full satisfaction of their lien claims, the lienholders have agreed to accept the total sum of: $ (Provide requesfed information on each lienholder and certam other medical service providers below) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be pard 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 (i)(A) Provider (name) (B) Address; (C) Amount charged $ (D) Amount paid (whether or not by insurance) $ ( (E) Negotiated reduction, if any. $ ( (F) Amount to be paid from proceeds ofsettlementor)udgment. $ I (ii) (A) Provider (name) (B) Address. (C) Amount charged: $ (D) Amount paid (whether or not by insurance): $ ( ) (E) Negotiated reduction, if any $ ( ) (F) Amount to be paid from proceeds of settlement or judgment: $ j C7 Continued on Attachment 13b(5). (Provide information about addiiional prowders in the above format, mcluding providers pard or lo be paid by pebti oner for which reimbursement is requested in item 13b(1) above you may use form MC-350(A-13b(5)) for this purpose.) MC-350IRay January 1,2011I PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Paaa 5 ay 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous} MC-350 CASE NAME 011SE NUMBER arter, et al. v, Bassow, et al. 20CV01472 14 The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement or judgment a Total amount of attorney's fees for which court approval is requested $ j3,333 33 (if fees are requested, attach as Attachment 14a, a declaration from the a(torney explaining lhe basis for ihe request, including a discussion of applicable factors listed in rule 7 955(b) of the Cal Ru/es of Court Respond to item 18a(2) on page 7 and attach a copy of any written attorney fee agreement as Attachment 18a.) 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: Items Pavees (names l Amounts $ Fees Filing Butte County Superior Court $ 154 33 $ $ $ $ $ $ $ $ $ Continued on Attachment 14b. Tomt: 5 154 33 I 15. Reimbursement of expenses paid by petitioner a. b ~ Mv Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested Petitioner has paid (or become obhgated to pay) the following total amounts of the claimant's expenses for which (1)~ reimbursement is requested ~ Medical expenses listed in item 13 $ (2) (3)~ Attorney's fees included in the total fee amount shown in item 14a. Other expenses included in the total shown in item 14b: Total: $ $ $ j (Attach proofs af the expenses incuned end peymenls made or obligations ta pay incuned, e.g, bills or invoices, canceled checks, credit card statements, explanatians af benefits from insurers, etc.) 16. Net balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or)udgment remaining for the claimant after payment of all requested fees and expenses is. 29,845 67 $j 17 Summary a. Gross amount of proceeds of settlement or judgment for claimant. $ 33,333.33 b Medical expenses to be paid from proceeds of settlement or judgment $ 0 c Attorney's fees to be paid from proceeds of settlement or judgment: $ 3,333 33 d. Expenses (other than medical) to be paid from proceeds of settlement or judgment " $ e Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): $ ( 3,487.66 f. Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) fram (a)): $ j29,845.67 Jaa ary MC-330 lRe 1, 20111 Payee oi10 PETITION TO APPROVE COIIIIPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME CASE NUMBER arter, et al. V. Bassow, et al. 20CV01472 18. a. (1) ~ Information about attorney representing or assisting petitioner Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the claim asserted. (Go lo item 19.) (2) ~y asserted ~ Petitioner has been represented or assisted by an attorney in prepanng this petition ar with respect to the claim Petitioner and the attorney do not ~K do have an agreement for services provided in (if you answered udo, " attach a capy of the agreement as connection with the claim giving rise to this petition. Attachment 18a, and complete items 18b.-18f) b. The attorney who has represented or assisted petitioner is (name) Adam Sorrells (1) state Bar number: 160226 (2) Law firm: Law Office of Adam Sorrells (3) Address. 60 Independence Circle, Suite 100, Chico, CA 95973 (4) Telephone number (530) 893-9900 c The attorneY ~y has not ~ has received attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving nse to this petition (if you answered ahas,"identify the person who paid the fees or other compensation, the amounts paid, and the dales of payment): From whom lnamesl Amounts Dates d ~ Continued on Attachment 18c. The attorney ~K did not ~ did become concerned with this matter, directly or indirectly, at the instance of a party against whom the claim is asserted ore party's insurance carrier (lf you answered adld," exp/ain the circumstances in Attachment 18d e The attorney ~) is not [Q is representing or employed by any other party or any insurance carrier involved in the matter. (if you answered "is, " identify the party or earner and explain lhe relationship in Attachment 18e ) The attorney ~ does not ~P does expect to receive attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim givmg nse to this petition. (if you answered "does," identify the person who will pay the fees or alber compensation, the amounts lo be paid, and the expected dates of payment): From whom (names) Amounts Exaected dates Daniel Castillo (21st Century Ins.) $ 3,333.33 TBD Daniel Castillo (21st Century Ins.) $ 3,333.34 TBD $ $ $ M Continued on Attachment 18f. Januaa1,2011i MC-3301R 0 PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM 0 0 20110 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR IIIIINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME CASE NUMBER arter, et el v Bassow, et el. 20CV01472 19 Disposition of balance of proceeds of settlement or judgment a. ~ Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows 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 noz (1) [ j $ of the proceeds in money or other property will be paid or delivered to the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money (2) ~ or other property is specified in Attachment 19a(1) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disabihty Petitioner requests authonty to deposit or invest $ of the money or other property to be paid or dehvered under 19a(1) with one or more financial institutions in this state or with a trust company, subject to 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 speafied 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 authonty to deposit or transfer these proceeds as follows (check all that apply): (a) C3 $ 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) (b) H $ will be invested in a single-premium deferred annuity subiect to withdrawal only on order of the court The terms and conditions of the annuity are specified in (c) ~ Attachment 19a(3) $ will be transferred to a custodian for the benefit of the minor under the Cahfornia 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) (d) %$approved will be transferred to the trustee of a trust that is either created by or of in the order approwng the settlement or the judgment gwen or to be given for the minor. This trust is revocable when the minor attains the age of 16 years and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The (e) ~ ~ terms of the proposed trust and the properly to be transferred are specified in Attachment 19a(3) $ A copy of the (proposed) ludgment is attached as Attachment 4c. will be transferred to the trustee of a spemal needs trust under Probate Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a disabibty. The terms of the proposed speaal needs trust and the properly to be transferred are spemfied in Attachment 19a(3). MC.350 [Roy January 1, 3011] Pflaa 8 of 10 PETITION TO APPROVE COINPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME CASE NUMBER arter, et el v Bassow, et el 20CV01472 19. Disposition of balance of proceeds of settlement or judgment (cont ) Petitioner requests that the balance of the proceeds of the settlement orjudgment be disbursed as follows: b. ~d 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 a/l thai apply). (1) ~ be appointed will estate of the minor or a conservator of the estate of the adult person with a disability A guardian of the $ of money and other property will be paid or delivered to the person so appointedThe money or other property are specified in Attachment 19b(1). (2) H $ of money will be deposited in insured accounts in one or more