Preview
Ii)IC-350
*TroRNEYonpArtw'wmouTATTDRNEYjntame staresa Adam Sorrells SBN 160226
mae,anrraddr aai FOR COURT USE ONLY
Law Office of Adam Sorrells
60 Independence Circle, Suite 100
Chico, CA 95973
(530) 893-9900
TELEr HoNE No (530) 893 9901
Fax No joplonag
E MAIL ADDRESS joPfionali
eaq27@COmCaat.net
ATTORNEY FOR jâ„¢7 KamerOn Carter 9/8/2020
SUPERIOR COURT OF CALIFORNIA, COUNTY OF BUTTE
sTREETADDREss 1775 Concord Avenue
ADDRESS
MAILING
Chico, CA
Cllv AND ZIP CODE 95928
ERANOH NAME North Butte County Courthouse
CASE NAME CASE NUMBER
Bassow, et al.
Carter, et al. v 20CV01472
HEARING DATE
PETITION TO APPROVE: ~v COMPROI)iIISE OF DISPUTED CLAIM
COMPROMISE OF PENDING ACTION September 23, 2020
Minor ~
DISPOSITION OF PROCEEDS OF JUDGMENT
Person With a Disability
NOTICE TO PETITIONERS:
TBA TIME 9 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 tn which a minor or a person with a dtsabfbty (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 attend the heartng 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 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)udgment 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.
1 Petitioner (name) Jeremy Boch
2. Claimant (name) Kameron Carter
a Address 212 W. 22nd Street, Chico, CA 95928
b Date of birth: c. Age " d. Sex: e. K Minor M Person with a disability
3
a. ~
Relationship Petitioner's relationship to the claimant (check all applicable boxes).
Parent g ~v Court ordered legal guardian
Other relationship (specify)
b
c. ~
~V
M
Guardian ad litem
Guardian
d.
e.
f
~
~
Conservator
Disabled adult claimant is a petitioner
(See inslruclions for riems 3e and 31 below J
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f.
(if you checked item 3e or 3f, slate facts on Attachment 3e or 3f shomng that the claimant has capacity under Probate
Code section 812 lo petition or consent io a peiilion. Only an aduii claimant who has sufftcient capacity and who does not
have a conservator of ihe estate may petition or consent io a petition
See Probate Code section 3613)
4.
a.
b
~
Nature of claim
~
The claim of the minor or adult person with a disability:
Has not been filed in an action or proceeding
(Compjeie items 5-23)
Is the sub)act of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
Name of court:
Case no. Tnal date (Complete items 5-23.)
Page
1ot 10
Fo«Adopted for PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM CodeofCIPmo d re,5372etaeq,
AllematMa d I N Uae prob
t code,] 3500 etaeq,
J d oat Counor of Cairo
a
Januarr I, 2011l
MC-350 IRe
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal R
I fCourt,rurea31354,
7 101, 7 550, 7 051
JUDGII)IENT FOR NIINOR OR PERSON WITH A DISABILITY nn oourfa oa go
(Miscellaneous)
IIIIC-350
CASE CASE NUMBER
NAME'rter,
et al. v
Bassow, et al. 20CV01472
4, Nature of claim The claim of the minor or adult person with a disability:
c. ~r 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):
3 )33,333 33
Defendants (nsmesl
Jackson Dallas Bassow
Daniel Castillo
Additional defendants listed on Attachment 4.~ The judgment was filed on (dale).
(Attach a copy of ihe (proposed) judgment as Allachmenl 4c and complete items f3-23)
5. ~r 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'ctoria Nystrom (Decedent), Jackson Dallas Bassow (Defendant dnver);
Daniel Castillo (Defendant owner); Marianna Castillo (Bassow's passenger)
6. ~r
~ Continued on Attachment 5
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (descnbe)
Kameron Carter is the son of decedent Victoria 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 MsVictona Nystrom was operating Ms Nystrom sustamed fatal iniunes as a result.
Continued on Attachment 6
7. ~v'njuries
The following injunes were sustained by the claimant as a result of the incident or accident (describe)i
Wrongful death case
Continued on Attachment 7.
8. ~ Treatment
The claimant received the following care and treatment for the iniunes described
in item 7(descn'be):
N/A wrongful death case
Continued on Attachment 8.
Jaaeanr
MC-330[Rev 2011l PETITION TO APPROVE CONIPROMISE OF DISPUTED CLAINI P 0 20110
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
9 ~ Extent of injuries and recovery (An onginal ore photocopy of all doclors'repons conlaming a diagnosis of and prognosis
for the claimant's injunes, and a report of the claimant's present conor(ion, musl be attached lo ibis petition as Attachment 9
a. ~ A new reportis nol necessary so long as a previous report accurately descnbes the claimanl's current condihon
)
The claimant has recovered completely from the effects of the inlunes described in item 7, and there are no
b ~ permanent injunes.
The claimant has not recovered completely from the effects of the injunes described in item 7,
and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries)
N/A wrongfuldeath case
~ Continued on Attachment 9b.
~ The claimant has not recovered completely from the effects of the iniunes descnbed in item 7, and the following injunes
from which the claimant has not recovered are permanent (descnhe the permanentinjuries):
N/A wrongfuldeath case
Continued on Attachment 9c.
10. ~v 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 ~V 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 defendants named below is (specify): $ i33,333 33
b The defendants and amounts offered by each are as follows (specify):
Defendants (namesl Amounts
Jackson Dallas Bassow 0
$
Daniel Castillo (By 21st Century Insurance) $ 33,333.33
$
$
$
Defendants and amounts offered continued on Attachment 11
c. The terms of settlement are as follows (if the settlement is lo be paid ininslallmenls, both the lolal amount and the
present value of the settlement musl be included):
A lump sum payment of $ 10,000.00 on October 6, 2027
A lump sum payment of $ 28,935.94 on October 6, 2034
These payments have a present value of $ 29,845.67 — the amount Kameron Carter, a minor,
willreceive after fees and
costs have been deducted
~ Contmued onAttachment11
en1,201II
MC-300[Rev Je PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM P 0 erie
3
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGIIIIENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME CASE NUMBER
arter, et al. v
Bassow, et al. 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 ansing out of the same incident or acadent that resulted in the claimant's injury.
b. ~y 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 inadent or accident that resulted in the
claimant's injury.
(1)
(2) Petitioner~K is not ~
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 listed under item 15).
(if you answered "is, " explain in Atlachmenl 12 the circumstances and the effect your claim has on the
(3) petitioner ~/ is not ~
proposed co~mromise of the claim described in this petilion )
is a plaintiff in the same action with the claimant
(if you answered "is," explain in Atlachmenl 12 the mrcumslances and the effect your claim and ils disposition
has on the proposed compromise of the claim or ection described in ibis petition.)
(4) M Petitioner would receive money under the proposed settlement
(5) The settlement payments are to be apportioned and distributed as follows:
Other olaintiffs or claimants fnamesl Amounts
Ambrosia Carter 33,333.33
Daisy Boch
$ 33,333 34
$
~
(6)
$
Additional plaintiffs or claimants and amounts are listed on Attachment 12
Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment12.
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 medicalexpenses $
(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
$ 10
b.
(1) ~
Medical
~
expenses were paid and are to be reimbursed from proceeds as follows:
Paid by petitioner in the amount of $ lg
(2)
(a) ~
Paid by pnvate health insurance or a self-funded plan under:
~ An Employee Retirement Income Secunty 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)
(ii)
~
Amount of reimbursement to the plan from proceeds of settlement or judgment:
M
No reimbursement is requested by the plan.
Reimbursement is to be made to the plan and:
(A) M There is a contractual reduction of $
( )
(B) 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: $ I
MC-300IRev Jaa aor
12011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 4 of 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 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
b.
(3) ~
Medical expenses were paid and are to be reimbursed from proceeds as follows:
Paid by Medicare in the amount of: $ N/A
less the statutory reduction in the amount of
$ ( )
for a total reimbursement to Medicare in the amount of: Sl
(4) ~ (Allach a copy of the final Medicare demand letter or lelter agreement as Aitachmenl 13b(3) )
Paid by Medi-Gal in the amount of
~ $ N/A
(a)
~ ~
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 copy of the notice and proof of its dekvery is attached.
(b) ~ was filed in this matter on (date):
Notice of this claim or action has not been given to the State Director of Health Care Services.
(c) ~ (Explain why notice has not been given in Altachment 13b(4) )
In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount ot $ I
(Attach a copy of the final Medi-Cal demand letter or letler agreement as Attachmenl 13b(4) )
(d) ~ Petitioner is entitled to a reduction of the Medi-Cal ken under Welfare and Institutions Code
(i)
(ii)
~
section 14124.76 and:
~ Is filing a motion seeking a reduction of the lien concurrently with this petition.
Requests that the court reserve jurisdiction over this issue
The amount of the lien in dispute is
(5) ~ (a)
expenses
$
There are one or more statutory or contractual liens of medical service providers for payment of medical
The total amount claimed under these liens is:
$ N/A In full satisfaction
of their hen claims, the lienholders have agreed to accept the total sum of $
(Provide requested informatron on each lienholder and certain 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 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 )udgment 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 ofsettlementorludgment $
(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 oriudgment$ j
Continued on Attachment 13b(5). (Provide information about additional pmvidersin the above format,
including providers paid or to be paid by petitioner for which rermbursament is requested in item 13b(1)
above. You may use form MC-350(A-13b(5)) for this purpose.)
Ja
Mc-350 IRa n 1. 201II 00
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM 0 f10
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
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: $ (3,333 33
(lf fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request, inc/uding
a discussion of applicable factors ksted in ru/e 7 955(b) of the Cat
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 acmdent, and should be paid out of claimant's share of the proceeds of the settlement or judgment:
Items Pavees (names) Amounts
$
Filing Fees Butte County Supenor Court $ 154 33
$
$
$
$
$
$
$
$
$
Continued on Attachment 14b Totati $ (154 33
15. Reimbursement of expenses paid by petitioner
a EH Petitioner has paid none of the claimant's expenses listed
in items 13 and 14 for which reimbursement is requested.
b. M Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which
(1) ~
reimbursement is requested
~ Medical expenses hated 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 of the expenses incuned and payments made or obligations to pay incuned, e g, bills or invoices,
canceled checks, credit card statements, explanations ofbenefits from insurers, etc)
16. Net balance of proceeds for the claimant
The balance of the proceeds of the proposed settlement or ludgment remaining for the claimant
after payment of all requested fees and expenses is:
$ ) 29,845.67
17 Summary
a. Gross amount of proceeds of settlement oriudgment 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 'ud 9 ment
(add (b), (c), and (d)): $ ( 3,487.66
f Balance ot proceeds of settlement or ludgment available for claimant after payment of all
fees and expenses (subtract (e) fiom (a)) $ j29,845.67
MC-330 iR
January2011i
1, a*00 0 o110
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAINI
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Misceganeous)
NIC-380
CASE NAME CASE NUNEER
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 prepanng this petition or in any other way with
respect to the claim asserted. (Go lo item 19)
~v'etitioner has been represented or assisted by an attorney in prepanng this petition or with respect to the claim
(2)
asserted ~
Petitioner and the attorney do not ~v'o
connection with the claim giving disa to this petition
have an agreement for services provided in
(If you answered ndo,n attach a copy of the agreement as
Attachment 18a, and complete items 18b -18f)
b The attorney who has represented or assisted petitioner is (name) Adam Sorrells
0) 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) 693-9900
c. The attorney ~u'as 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 rise to this petition
(lf you answered "has," idenlify the person
who paid the fees or other compensation, the amounts paid, and Ihe dates of payment)i
From whom (names) Amounts Dates
d.
~ Continued on Attachment 18c
The attorney ~X did not ~ did become concerned with this matter, directly or indireclly, at the instance of a party
against whom the claim is asserted or a party's insurance carrier.
(If you answered adrd," explain the circumstances in
Atlachment 18d.)
e The attorney ~ is not ~Z is representing or employed by any other party or any insurance carrier involved in the
matter. (If you answered hs, " identify the party or earner and explarn the felalronship in Attachment 18e.)
f. The attorney
requested in
~ does not ~u'oes expect to receive aNorney's fees or other compensation in addition to that
this petition for services provided in connection with the claim giving nse to this petition
(If you answered "does,"
identify the person who will pay the fees or other compensation, the amounts lo be paid, and the expecled dales of payment):
From whom (names) Amounts Exoected dates
Daniel Castillo (21st Century Ins.) $ 3,333.33 TBD
Daniel Castillo (21st Century Ins.) $ 3,333 34 TBD
$
$
$
M Continued on Attachment 18f.
Irlc-350IRey January 1,2011l
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 1 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGNIENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME CASE NUMBER
arter, et al. v, Sassow, et al 20CV01472
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. M There is a guardianship of the estate of the mmor or a conservatorship of the estate of the adult person with a
disability filed in (name of
court)'ase
no:
(1)H $ 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 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 finanmal institutions in this state or with a trust
company, subject to withdrawal only as authonzed by the court. The money or other property and the name,
branch, and address of each finanmal institution or trust company are spemfied in Attachment 19a(2).
(3) ~ Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or
conservatorship estate Petitioner requests authority to deposit or transfer these proceeds as follows
(check all that apply):
(a) %$institutions in
will be deposited in insured accounts in one or more finanaal
this state from which no withdrawals can be made without a court order
(b) ~ The name, branch, and address of each depository are specified in Attachment 19a(3).
$ will be invested in a single-premium deferred annuity subject to
withdrawal only on order of the court
The terms and conditions of the annuity are spemfied in
(c) ~ Attachment 19a(3)
$ will be transferred to a custodian for the benefit of the minor under the
Cakfornia 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) &$approved wdl be transferred to the trustee of a trust that is either created by or
of in the order approving the settlement or the judgment given or to be given for the
minor This trust is revocable when the minor attains the age of 18 years and contains all other
terms and conditions determined to be necessary by the court to protect the minoys interests
The
(e)[ j$
~terms of the proposed trust and the property to be transferred are specified in Attachment 19a(3)
A copy of the (proposed) lodgment is attached as Attachment 4c.
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
The terms of the proposed special needs trust and the property to be transferred are
disability
speafied in Attachment 19a(3)
Jaauarr 1,2511r
MC 35D lRav
eaearie
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAINI r
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 at
v. Bassow, et at 20CV01472
19 Disposition of balance ofproceeds of settlement or judgment (cont.)
Petitioner requests that the balance of the proceeds of the settlement oriudgment be disbursed as follows:
b. ~P 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 ot the settlement or)udgment be disbursed as follows
(check all that apply):
(1) ~ A guardian of the
willbe appointed.
estate of the minor or a conservator of the estate of the adult person with a disability
$ of money and other property will be paid