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MC-351
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address( FOR COURT VSE ONLY
Jqor Kopilenko (242127)
Allegiance Law
871 Paqe Street, Suite 5, San Francisco, CA 94117
TELEPHONE NO.
E-MAILADDRESS
41 5-404-6395
(Optionatl'TTORNEY
4 1 5-738-2406
FAX NO (Opthonalj. III,KD
SAN MATEO COUNTY
FOR (Name(LaWrenCe Smith, Jr.
sUPERIoR coURT QF GALIFoRNIA coUNTY oF Sait Mateo JUN y 6 20I4
sTREETADDREss 400 County Center
MAILINGADDRESS
coDE
GITY AND zIP Redwood City. CA 94063
BRANCH NAME Br
CASE NAME:
Smith v. Passion, et al
ORDER APPROVING: CASE NUMBER
COMPROMISE OF DISPUTED CLAIM CLJ523853
COMPROMISE OF PENDING ACTION
DISPOSITION OF PROCEEDS OF JUDGMENT ANY'EPT.:
HEARING DATE, IF
Minor ~ Person With a Disability
1. Petitioner(name): Jeromiah Smith and lawrence Smith has petitionedfor court approvalof a
proposed compromise of a disputedclaim of aminor or a pendingactioninvolving a minor or a personwith a disability or a
proposed dispositionof theproceeds of a judgmentfor a minor or a personwith a disability.
2. Hearing
a. ~< No hearing was held.The petition is an
expedited rule 7.950.5
petition under of theCalifornia Rulesof Court.
b H Date: Time: Dept.:
c. Judicial officer:
3. Relationship to claimant
a. ~
Petitioner has
~ Parent
or relationships
the following relationship to claimant(check all applicable
boxes):
b.
c. ~
~
Guardian
Guardian
ad litem
d.
e. ~ Conservator
Claimant, an adult person
Other (specify):
with a disability, is the petitioner.
4.
a. ~
Claimant
~
(name):
is a minor.
b.
(1) ~
is a "personwith a disability" within the
An adult.
(a) M
Claimant's date
meaning of Probate
of birth is (specify):
Without a conservator.Claimant has
Code
capacity
section3603 who is:
to consent within the meaning
to this order, of
Probate Code section812, and has consented to this order.
(b) M A conservatee; a person for whom a conservator may be appointed; or without capacityto
5. Defendant
(2) ~ consent
A minor described
to this order,
in Probate
within the meaning
Code section
of Probate
3603(b)(3).
Code section812.
The claim or action to be
compromised or the judgment
is asserted, is entered,against(name of settling orjudgmentdefendant or
defendants (the "payer")):
Joe Passion and Noe Passion
Paoe1of 4
Adopted'm Mande."> Use
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING
Judkchal Council of Califomhe Probate Code, 9 3500 et seq,
Mc-351 IReu. Janus',
zo1ol ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR cai. Ruies of coun, rules 3.1394. 7953
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-351
CASE NAME: CASE NUMBER.
—Smith v. Passion, et al CLJ523853
6. THE COURT FINDS that all notices requiredby law have been given.
7. THE COURT ORDERS
a. The petition is granted
and the proposed compromise of claim or action
or theproposed dispositionof the proceeds of the
judgment is approved.The gross amount or valueof thesettlementor judgment in favor of claimant
is $ ~6,839.00
b. H Until further order of the court, jurisdiction is reserved
Welfare and Institutions Codesection14124.76.
to determine
The amount shown
a claim for a reduction
payable to the
of a Medi-Cal lien under
Department of Health Care Services
in item 7c(1)(d) of this order is the full amount
of the lien claimed
by the department to reduction
Cut is subject on further
order of the court upon
determination of the daim for reduction.
c. The payer shall disbursethe proceeds of the settlementor judgment approved by this order in the following manner:
(1) Payment of fees and expenses
Fees and expenses shallbe paid by one or more checks or drafts,
drawn payable to the order of the
petitioner andthe
petitioner's
attorney,if any,or directly to third parties to receive
entitled payment identified in this order for the following
items of expense or damage, which are hereby authorizedto be paid out of the proceedsof the settlement
or judgment:
(a) ~< Attorney'sfees in the total amount
of: $ Il,577.254 payable to (specify):
(b) ~ Reimbursement
petitioner's
for medicaland all other expensespaid by thepetitioner or the
630 00
~ attorney in the total amount
of: $
(c) Medical, hospital,
ambulance, nursing,and other like expenses payable directly to
providersas follows, in the total amount
of: $ $ 92.48
(i) Payee (name):Medi-Cal
(A) Address: Dept. Health Care Svcs., P.O. Box 997425, sacramento, CA 95899
(a) Amount: $ "32 48
(ii)Payee (name):Makati Chiropractic
(A) Address: 731 Hickey Blvd., Pacifica, CA 94044
660.00
(d) ~ ~ (B) Amount: $
Continued
Other authorized
on Attachment
disbursements
7c(1)(c).
payable
(Provide information about additional payeesin
directly to third parties
in the total amountof: $
the above format)
(Describe and statethe amount of each item and providethe name and address of each payee):
Continued on Attachment 7c(1)(d).
(e) ~< Total allowance for feesand expenses from the settlement or judgment: $ l2,899.73
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Page g et 4
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-351
CASE NAME: CASE NUMBER
—Smith v. Passion, et al CLJ523853
7. THE COURT ORDERS (cont.)
c. The payer shall disbursethe proceeds of the settlementor judgment approved by this order in the following manner:
(2) Balance
The balance of the settlementor judgment availablefor claimantafter payment of all allowed
fees and expenses is: $ I3,939.27
The balance shall be disbursed asfollows:
(a) ~~ By one or more checks or drafts in the total amount $ 3,939.27
of (specify):
drawn payable to the order of the petitioner as
trusteefor the claimant.
Each such check or draft must bear
an
endorsement on the face or reversethat it is for deposit
in one or more interest-bearing,
federally insured
accounts in the name of the petitioner as
trustee for the claimant,
and no withdrawals may be made from the
accounts except as provided in theOrder to Deposit Money Into Blocked Account (form MC-355), which is
(b) ~ signed contemporaneously
By the following method(s)(describe each
("blocked
with this order
method,
account").
including the amount to be disbursed ):
~
(c) ~ Continued
If money
of the state
on Attachment
Department
7c(2)(b).
is to be paid to a special
of Health
needs
Care
trust under
Services,the
Probate
state
Code section
Department
3604, all statutory
of Mental Health,the
liens in favor
state
Department of Developmental Services, and any city and must first be
county in California satisfiedby the
following method (specify):
8. ~~ Further
~
orders
Continued on Attachment
of the court concerning
7c(2)(c).
blocked accounts
The court makes the following additional
orders concerning any part of the
balance ordered to be deposited in a blocked
account under item 7c(2)(a):
a. Within 48 hoursof receiptof acheck or draft describedin item 7c(2)(a),
the petitioner and
the petitioner's
attorney,if
any,must deposit the check or draft in the
petitioner's
name as trusteefor the claimant in one
or more blocked accounts
at (specify name,branch,and address of each depository,and the amount of each account):
Chase Bank, Divisadero Branch, 401 Divisadero St., San Francisco, CA 94117,
$ 3,939.27 to be deposited.
Continued on Attachment 8a.
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING of 4
Page 3
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-351
CASE NAME: CASE NUMBER
—Smith v. Passion, et al CLJ523853
8. Further orders of the court concerning blocked accounts
The court makes the following additional
orders concerning any part of the
balance ordered to be deposited in a blocked
account under item 7c(2)(a):
b. The petitioner andthepetitioner's
attorney,if any,must deliver to each
depository at the time of deposit
threecopies of
theOrder to Deposit Money Into Blocked Account (form MC-355), which is signed contemporaneously with this order,
and threecopies of theReceipt and Acknowledgment of Order for the Deposit of Money Into Blocked Account (form
petitioner's
MC-356). The petitioner or the attorney must file a copy of the
receipt with this court within 15 days
of the
deposit.The sole of the
responsibilities petitioner and
the petitioner's
attorney,if any,
are to placethe balance in a
blocked account or accounts and to timely file a copy of the
receipt.
c. The balance of the proceeds of the settlementor judgment depositedin a blocked account or accounts under item
(1) ~
7c(2)(a)may be withdrawn only as
No withdrawals
follows (check
written order under this case
name
(1)
of principal or interest
or
may be
and
(2)):
made
number,
from the blocked
signed by a judge,
account
and
or accounts
bearingthe seal
without a further
of this court. The
money on depositis not subjectto escheat.
(2) ~< The blocked account or accounts belong to a minor. The minor was born on (date):11/21/2002
No withdrawals of principal or interest
may be made from theblocked account or accountswithout a further
written order under this case
name and number, signed by a judicial officer, and
bearing the sealof this
court, minor attains
until the the age of 18 years.
When the minor attains
the age of 18 years,the depository,
without further order of this court,
is authorizedand directedto pay by check or draft directly to the former
minor, upon proper demand, all moneysincluding interest
deposited under this order.
The money on deposit
9. ~ is not subject
Authorization to execute
to escheat.
settlement documents
a. ~
The petitioner is authorized
to execute
petitioner is authorized
and
settlement
Upon receipt of the full amount
directed
documents
of the settlement
to execute and
as
sum
follows (check only one):
approved by this order and
deliver to the
payer
the deposit
and
a full, complete,
of funds,the
final release
and
discharge of any andall daims and demands of theclaimant by reason of the accidentor incident described
in
thepetition andthe resultant
injuries to the claimant
and a properly executeddismissal with prejudice.
b. ~< The petitioner is authorized
and directed to executeany and all documents reasonably necessary to carry out
c. ~ the terms of the settlement.
The petitioner is authorized
and directed(specify):
Continued on Attachment 9c.
10. Bond is ~ ordered and fixed in the amountof: $ not required.
11.
12.~A copy of this order shall
Additional orders
The court makes
be served on the payer forthwith.
the following additional
orders (specify):
~ Continued on Attachment 12.
oate:
$//g//e/ ~ rx /
JUDICIAL OFFICER
SIGNATURE FOLLOWS LAST ATTACHMENT
Mc-»f lRa»a«a~ I»«i ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING of 4
Page 4
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
Preview
MC-351 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address( FOR COURT VSE ONLY Jqor Kopilenko (242127) Allegiance Law 871 Paqe Street, Suite 5, San Francisco, CA 94117 TELEPHONE NO. E-MAILADDRESS 41 5-404-6395 (Optionatl'TTORNEY 4 1 5-738-2406 FAX NO (Opthonalj. III,KD SAN MATEO COUNTY FOR (Name(LaWrenCe Smith, Jr. sUPERIoR coURT QF GALIFoRNIA coUNTY oF Sait Mateo JUN y 6 20I4 sTREETADDREss 400 County Center MAILINGADDRESS coDE GITY AND zIP Redwood City. CA 94063 BRANCH NAME Br CASE NAME: Smith v. Passion, et al ORDER APPROVING: CASE NUMBER COMPROMISE OF DISPUTED CLAIM CLJ523853 COMPROMISE OF PENDING ACTION DISPOSITION OF PROCEEDS OF JUDGMENT ANY'EPT.: HEARING DATE, IF Minor ~ Person With a Disability 1. Petitioner(name): Jeromiah Smith and lawrence Smith has petitionedfor court approvalof a proposed compromise of a disputedclaim of aminor or a pendingactioninvolving a minor or a personwith a disability or a proposed dispositionof theproceeds of a judgmentfor a minor or a personwith a disability. 2. Hearing a. ~< No hearing was held.The petition is an expedited rule 7.950.5 petition under of theCalifornia Rulesof Court. b H Date: Time: Dept.: c. Judicial officer: 3. Relationship to claimant a. ~ Petitioner has ~ Parent or relationships the following relationship to claimant(check all applicable boxes): b. c. ~ ~ Guardian Guardian ad litem d. e. ~ Conservator Claimant, an adult person Other (specify): with a disability, is the petitioner. 4. a. ~ Claimant ~ (name): is a minor. b. (1) ~ is a "personwith a disability" within the An adult. (a) M Claimant's date meaning of Probate of birth is (specify): Without a conservator.Claimant has Code capacity section3603 who is: to consent within the meaning to this order, of Probate Code section812, and has consented to this order. (b) M A conservatee; a person for whom a conservator may be appointed; or without capacityto 5. Defendant (2) ~ consent A minor described to this order, in Probate within the meaning Code section of Probate 3603(b)(3). Code section812. The claim or action to be compromised or the judgment is asserted, is entered,against(name of settling orjudgmentdefendant or defendants (the "payer")): Joe Passion and Noe Passion Paoe1of 4 Adopted'm Mande."> Use ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Judkchal Council of Califomhe Probate Code, 9 3500 et seq, Mc-351 IReu. Janus', zo1ol ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR cai. Ruies of coun, rules 3.1394. 7953 MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-351 CASE NAME: CASE NUMBER. —Smith v. Passion, et al CLJ523853 6. THE COURT FINDS that all notices requiredby law have been given. 7. THE COURT ORDERS a. The petition is granted and the proposed compromise of claim or action or theproposed dispositionof the proceeds of the judgment is approved.The gross amount or valueof thesettlementor judgment in favor of claimant is $ ~6,839.00 b. H Until further order of the court, jurisdiction is reserved Welfare and Institutions Codesection14124.76. to determine The amount shown a claim for a reduction payable to the of a Medi-Cal lien under Department of Health Care Services in item 7c(1)(d) of this order is the full amount of the lien claimed by the department to reduction Cut is subject on further order of the court upon determination of the daim for reduction. c. The payer shall disbursethe proceeds of the settlementor judgment approved by this order in the following manner: (1) Payment of fees and expenses Fees and expenses shallbe paid by one or more checks or drafts, drawn payable to the order of the petitioner andthe petitioner's attorney,if any,or directly to third parties to receive entitled payment identified in this order for the following items of expense or damage, which are hereby authorizedto be paid out of the proceedsof the settlement or judgment: (a) ~< Attorney'sfees in the total amount of: $ Il,577.254 payable to (specify): (b) ~ Reimbursement petitioner's for medicaland all other expensespaid by thepetitioner or the 630 00 ~ attorney in the total amount of: $ (c) Medical, hospital, ambulance, nursing,and other like expenses payable directly to providersas follows, in the total amount of: $ $ 92.48 (i) Payee (name):Medi-Cal (A) Address: Dept. Health Care Svcs., P.O. Box 997425, sacramento, CA 95899 (a) Amount: $ "32 48 (ii)Payee (name):Makati Chiropractic (A) Address: 731 Hickey Blvd., Pacifica, CA 94044 660.00 (d) ~ ~ (B) Amount: $ Continued Other authorized on Attachment disbursements 7c(1)(c). payable (Provide information about additional payeesin directly to third parties in the total amountof: $ the above format) (Describe and statethe amount of each item and providethe name and address of each payee): Continued on Attachment 7c(1)(d). (e) ~< Total allowance for feesand expenses from the settlement or judgment: $ l2,899.73 ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Page g et 4 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-351 CASE NAME: CASE NUMBER —Smith v. Passion, et al CLJ523853 7. THE COURT ORDERS (cont.) c. The payer shall disbursethe proceeds of the settlementor judgment approved by this order in the following manner: (2) Balance The balance of the settlementor judgment availablefor claimantafter payment of all allowed fees and expenses is: $ I3,939.27 The balance shall be disbursed asfollows: (a) ~~ By one or more checks or drafts in the total amount $ 3,939.27 of (specify): drawn payable to the order of the petitioner as trusteefor the claimant. Each such check or draft must bear an endorsement on the face or reversethat it is for deposit in one or more interest-bearing, federally insured accounts in the name of the petitioner as trustee for the claimant, and no withdrawals may be made from the accounts except as provided in theOrder to Deposit Money Into Blocked Account (form MC-355), which is (b) ~ signed contemporaneously By the following method(s)(describe each ("blocked with this order method, account"). including the amount to be disbursed ): ~ (c) ~ Continued If money of the state on Attachment Department 7c(2)(b). is to be paid to a special of Health needs Care trust under Services,the Probate state Code section Department 3604, all statutory of Mental Health,the liens in favor state Department of Developmental Services, and any city and must first be county in California satisfiedby the following method (specify): 8. ~~ Further ~ orders Continued on Attachment of the court concerning 7c(2)(c). blocked accounts The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked account under item 7c(2)(a): a. Within 48 hoursof receiptof acheck or draft describedin item 7c(2)(a), the petitioner and the petitioner's attorney,if any,must deposit the check or draft in the petitioner's name as trusteefor the claimant in one or more blocked accounts at (specify name,branch,and address of each depository,and the amount of each account): Chase Bank, Divisadero Branch, 401 Divisadero St., San Francisco, CA 94117, $ 3,939.27 to be deposited. Continued on Attachment 8a. ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING of 4 Page 3 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-351 CASE NAME: CASE NUMBER —Smith v. Passion, et al CLJ523853 8. Further orders of the court concerning blocked accounts The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked account under item 7c(2)(a): b. The petitioner andthepetitioner's attorney,if any,must deliver to each depository at the time of deposit threecopies of theOrder to Deposit Money Into Blocked Account (form MC-355), which is signed contemporaneously with this order, and threecopies of theReceipt and Acknowledgment of Order for the Deposit of Money Into Blocked Account (form petitioner's MC-356). The petitioner or the attorney must file a copy of the receipt with this court within 15 days of the deposit.The sole of the responsibilities petitioner and the petitioner's attorney,if any, are to placethe balance in a blocked account or accounts and to timely file a copy of the receipt. c. The balance of the proceeds of the settlementor judgment depositedin a blocked account or accounts under item (1) ~ 7c(2)(a)may be withdrawn only as No withdrawals follows (check written order under this case name (1) of principal or interest or may be and (2)): made number, from the blocked signed by a judge, account and or accounts bearingthe seal without a further of this court. The money on depositis not subjectto escheat. (2) ~< The blocked account or accounts belong to a minor. The minor was born on (date):11/21/2002 No withdrawals of principal or interest may be made from theblocked account or accountswithout a further written order under this case name and number, signed by a judicial officer, and bearing the sealof this court, minor attains until the the age of 18 years. When the minor attains the age of 18 years,the depository, without further order of this court, is authorizedand directedto pay by check or draft directly to the former minor, upon proper demand, all moneysincluding interest deposited under this order. The money on deposit 9. ~ is not subject Authorization to execute to escheat. settlement documents a. ~ The petitioner is authorized to execute petitioner is authorized and settlement Upon receipt of the full amount directed documents of the settlement to execute and as sum follows (check only one): approved by this order and deliver to the payer the deposit and a full, complete, of funds,the final release and discharge of any andall daims and demands of theclaimant by reason of the accidentor incident described in thepetition andthe resultant injuries to the claimant and a properly executeddismissal with prejudice. b. ~< The petitioner is authorized and directed to executeany and all documents reasonably necessary to carry out c. ~ the terms of the settlement. The petitioner is authorized and directed(specify): Continued on Attachment 9c. 10. Bond is ~ ordered and fixed in the amountof: $ not required. 11. 12.~A copy of this order shall Additional orders The court makes be served on the payer forthwith. the following additional orders (specify): ~ Continued on Attachment 12. oate: $//g//e/ ~ rx / JUDICIAL OFFICER SIGNATURE FOLLOWS LAST ATTACHMENT Mc-»f lRa»a«a~ I»«i ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING of 4 Page 4 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous)