Preview
MC-350
ATTORNEY ORPARTY WITHOUTATTORNEY(Name,State
Barnumber,
andaddress): FOR COURTUSE ONLY
ena Dalby Pst (SBN 190207)
L
1013 Galleria Blvd., Suite 275 ELECTRONICALLY FILED
Roseville, CA 95678 Superior Court of California,
teLePHone no. (916) 677-2144 FAXNO.(Optional):
(916)677-2143 County of Placer
E-MAILADDRESS (Optional): 09/25/2020
ATTORNEY FOR(Name): Petitioner, RACHEL KENDALL By: Kathrine Zaragoza, Deputy Clerk
SUPERIOR COURT OF CALIFORNIA, COUNTY OF PLACER
streetaDDREss: 10820 Justice Center Drive
MAILINGADDRESS:
cityanpzipcope: Roseville, CA 95678
BrancHName: BillSantucci Justice Center
CASE NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
PETITION TO APPROVE: [__] COMPROMISE OF DISPUTED CLAIM HEARINGDATE:
COMPROMISE OF PENDING ACTION October 22, 2020
[_] DISPOSITION OF PROCEEDS OF JUDGMENT veer. 42 sme 8:30 a.m.
Minor [__] Person With a Disability
NOTICE TO PETITIONERS:
Except as noted below, you must use thisform to request court approval of(1) the compromise of adisputed claim of a minor,
(2) thecompromise ofa pending action or proceeding inwhich a minor or a person with a disability(includinga conservatee) isa
party, or(3) the dispositionof the proceeds ofa judgment for a minor or person witha disability.(See Code Civ. Proc.,§ 372: Prob.
Code, § 3600 etseq.) You and the minor or disabled person must attend the hearing on thispetition unless the courtfor good caus¢
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or
examining physician, and other evidence relatingto the merits ofthe 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 forapproval ofthe compromises of
certain claims and actions or the disposition ofthe proceeds of certainjudgments. Ifyour claim, action, orjudgment qualifiesfor
expedited consideration and you want to request you
it, must use form MC-350EX foryour request. See Cal. Rules ofCourt, rule
7.950.5.
1. Petitioner (name): RACHEL KENDALL
2. Claimant (name); LAUREN KENDALL, a minor
a. Address: 1650 Alblene Circle, Rocklin, CA 95765
b. Date of birth:08/09/05 c. Age: 15 d. Sex: Female e. Minor [__] Person with a disability
3. Relationship Petitioner'srelationshipto the claimant (check ail
applicable boxes):
a. Parent g. [__] Other relationship (specify:)
b. Guardian ad litem
c. [__]| Guardian
d. [-_] Conservator
e. [__] Disabled adultclaimant isa petitioner.(See instructionsforitems 3e and 3f below.)
f. (__] Disabled adult claimant's express consent to the relief
requested in thispetitionisprovided on Attachment 3f.
(if youchecked item 3e or 3f,state factson Attachment 3e or 3fshowing that the claimant has capacity under Probate
Code section 812 to petitionorconsent to apetition.Only an adultclaimant who has sufficient
capacity and who does not
have a conservator ofthe estate may petitionor consent toa petition.See Probate Code section 3613.)
4, Nature of claim The claim of the minor or adult person with a disability:
a. [__] Has not been filedin an action orproceeding. (Complete items 5-23.)
b. Isthe subject of a pending action or proceeding thatwill be compromised without a trialon the merits ofthe claim.
Name ofcourt: Placer County Superior Court
Case no.:SCV0044404 Trialdate: None (Complete items 5~23.)
Page 1
of10
Altemative
Mondatory
Use PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ‘°° orobateCode, 2500can
Judicial
MC-350
Councit
[Rev.
ofCalifornia
January
1, 2011}
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF eval Cal.
Rules
ofCourt,
rules
3.1384,
7.101,
7.950,
7.951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITYo 3 ation
Ss
(Miscellaneous) “@ Plus
MC-350
CASE NAME: Kendail v. Kilgore CASE NUMBER:
P SCV0044404
4. Nature of claim The claim ofthe minor or adultperson with a disability:
Cc. Isthe subject of a pending action orproceeding that has been orwill be reduced to a judgment for the claimant against
the defendants named below inthe total amount (exclusive ofinterest and costs) of (specifybelow):
$ [62,500
Defendants (names)
Michelle Monier Kilgore
[__] Additional defendants listedon Attachment 4. [__] The judgment was filedon (date):
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.)
5. Incident or accident The incidentor accident occurred as follows:
a. Date andtime: March 24, 2018
b. Place: 550 Long Meadow Lane, Lincoln, CA, County of Placer
c. Persons involved (names):Lauren Kendall
|__| Continued on Attachment 5.
6. [X] Nature of incident or accident
The facts,events, and circumstances of the incidentor accident are (describe): Claimant was legally on the
premises of Defendant MICHELLE MONIER KILGORE at a sleep over with Defendant's daughter.
Defendant KILGORE permitted soap and water to be applied to Defendant's trampoline to use itas a
slip and slide. The following morning Claimant and Defendant's daughter returned to the trampoline
and began jumping on it. The trampoline had not been appropriately cleaned, and soap remained
on the surface of the trampoline making issubstantially more slippery. Claimant began to jump, her
feet completely slipped out from under her and she landed awkwardly on her neck.
| _] Continued on Attachment 6.
7. Injuries
The followinginjurieswere sustained by the claimant as a resultof the incidentor accident (describe): Claimant tore
the ligaments in her neck.
[__] Continued on Attachment 7.
8. Treatment
The claimant received the following care and treatment forthe injuriesdescribed in item 7 (describe):
Claimant was seen and evaluated at Sutter Roseville Medical Center and UC Davis Medical Center.
She was required to wear a cervical collar and refrain from physical activity while ligaments healed.
She then underwent physical therapy to address some residual soreness.
[__] Continued on Attachment 8.
MC-$50[Rev.
January
1,2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page2 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
CASE NAME: Kendall MC-350
v. Kilgore CASE NUMBER:
SCV0044404
9. Extent of injuries and recovery (An originalor a photocopy of all
doctors‘ reports containing a diagnosis of and prognosis
for the claimant'sinjuries,and a report ofthe claimant's present condition, must be attached to thispetitionas Attachment 9.
A new report isnot necessary so long as a previous reportaccurately describes the claimant's current condition.
)
a. The claimant has recovered completely from the effects ofthe injuriesdescribed initem 7, and there are no
permanent injuries.
b. [__] The claimant has not recovered completely from the effectsof the injuriesdescribed in item 7, and the following injuries
from which the claimant has not recovered are tem porary (describe the remaining injuries):
L__] Continued on Attachment 9b.
c. [__] The claimant has notrecovered com pletelyfrom the effects ofthe injuriesdescribed initem 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries):
[__] Continued on Attachment 9c.
10. Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating tothe 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 fullyunderstands that ifthe compromise proposed inthis
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. 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 totalamount offered by alldefendants named below is(specify): $| 62,500
b. The defendants and amounts offered by each are asfollows (specify):
Defendants (names) Amounts
MICHELLE MONIER KILGORE 62,500
HS
FPP SF
[__] Defendants and amounts offered continued on Attachment 11.
c. The terms of settlement are as follows (ifthe settlement isto be Paid ininstallments, both the totalamount and the
present value ofthe settlement must be included):
[___] Continued on Attachment 11.
MC-350[Rev.
January1, 2011} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page3of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
Mc-350
CASE NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
12. Settlement payments to others
a. [X] No defendant named in item11b has offeredto pay money to any person or persons other than the claimant to
settleclaims arisingout of thesame incidentor accident that resulted inthe claimant's injury.
b. L By way of settlement, one or more defendants named initem 11b have also offered to pay money toa person or
persons other than claimant to settieclaims arisingout of thesame incidentor accident that resulted inthe
claimant's injury.
(1) The totalamount offered by alldefendants to others (specify): $
(2) Petitioner [| is not [J is aclaimant against the recovery ofthe claimant (otherthan for
reimbursement for expenses paid by petitionerand listedunder item 15).
(If youanswered "is,"
explain inAttachment 12 the circumstances and the effectyour claim has on the
proposed compromise ofthe claim described inthispetition.)
(3) Petitioner [__] isnot [ ]is a plaintiff
inthe same actionwith the claimant.
(if youanswered "is,"
explain in Attachment 12 the circumstances and the effectyour claimand itsdisposition
has on theproposed compromise of the claimor action described in thispetition. )
(4) [__] Petitionerwould receive money under the proposed settlement.
(5) The settlement payments are to be apportioned and distributedas follows:
Other plaintiffs
or claimants (names) Amounts
PAA en
$
[] Additional plaintiffs
or claimants and amounts are listedon Attachment 12.
(6) Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiffor 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 orjudgment
a. Totals
(1) Total medical expenses: $ 49,866
(2) Total outstanding medical expenses to be paid from the proceeds: 2
(3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds: $ LF
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(1) [__] Paid by petitionerin the amount of: $ LT
(2) Paid by private health insurance ora self-funded plan under:
(a) [-] An Employee Retirement Income Security Act (ERISA) insured plan.
(b) An ERISA self-funded plan.
(c) L__] A Non-ERISA insured plan.
(d) L_] ANon-ERISA self-funded plan.
(e) Amount paid by plan: $ 44,478
(f) Amount of reimbursement to the plan from proceeds of settlement orjudgment:
(i) [2] No reimbursement isrequested by the plan.
(ii) Reimbursement isto be made to the plan and:
(A) L__] There isa contractual reduction of $( )
(B) There isa negotiated reduction of $( 23,645 )
(C) [_] No reduction has been agreed to,
for atotal reimbursement tothe plan in the amount of: $
MC-350[Rev,
January
1,2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page4of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(3) L-_] Paid by Medicare in the amount of: $
less the statutoryreduction in the amount of: $ ( )
fora total reimbursement toMedicare in the amount of: $ LT
(Attach a copy of the finalMedicare demand letterorletteragreement as Attachment 7 36(3).)
(4) [__] Paid by Medi-Cal in the amount of $
(a) [__] Notice ofthisclaim or action has been given tothe State Director ofHealth Care Services under Welfare
and InstitutionsCode section 14124.73. A copy ofthe notice and proof of itsdelivery [__] is attached.
|_] was filedinthismatter on (date):
(b) [__] Notice of thisclaim or action has not been given to the State Director ofHealth Care Services.
(Explain why noticehas not been given inAttachment 13b(4).)
(c) [__] Infullsatisfaction ofitslien rights,Medi-Cal has agreed to accept reimbursement
inthe amount of: $
(Attach a copy of the finalMedi-Cal demand /etteror letteragreement as Attachment 1 30(4).)
(a) L_] Petitioner isentitledto a reduction ofthe Medi-Cal lienunder Welfare and InstitutionsCode
section 14124.76 ana:
(i)[J Isfilinga motion seeking a reduction of the lienconcurrently with this petition.
(ii)(__] Requests that the court reserve jurisdictionover thisissue.
The amount of the lienindispute is:$
(5) (a) There are one or more statutoryor contractual liens ofmedical service providers for payment of medical
expenses. The total amount claimed under these liensis: $ 49 601 __!n full
satisfaction
of theirlienclaims, the lienholders have agreed to accept the totalsum of: $ 22,333
(Provide requested information on each lienholder and certain other medical service providers below. )
(b) The name of each medical service provider thatfurnished care and treatment to claimant and (1)has a lienforall
or any part ofthe charges or (2)was paid (or willbe paid from the proceeds) by petitionerfor which petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction ofcharges, ifany;
and the amount to be paid from the proceeds of thesettlement orjudgment to each provider are as follows:
(i) (A) Provider (name): UMR (ERISA self-funded plan)
(B) Address: L-3994, Columbus, OH 43260-3994
(C) Amount charged: $ 44,478
(D) Amount paid (whether or not by insurance): $ ( )
(E) )Negotiated reduction, ifany: $( 23,645 )
( F) Amount tobe paidfrom proceeds of settlement or judgment: $ 20,833
(ii)(A) Provider (name): Health Advocates (for UC Davis Medical Center)
(B) Address: 21540 Plummer Street, Suite B, Chatsworth, CA 91311
(C) Amount charged: $ 5,123
(D} Amount paid (whether or not by insurance): $( )
(E) Negotiated reduction, if
any: $( 3,623 )
(F) Amount to be paid from proceeds of settlement or judgment: $
|] Continued on Attachment 13b(5). (Provide information about additionalproviders in theabove format.
includingproviders paid orto be paid by petitioner forwhich reimbursement isrequested initem 13b(1)
above. You may use form MC-350(A-13b(5)) forthis purpose.)
MC-350[Rev.
January4, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page5of10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MiC-350
CASE NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
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 tobe reimbursed from proceeds of settlement or judgment
a. Total amount of attorney'sfees for which courtapproval isrequested: $ 15,331
(iffees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis forthe request, including
a discussion of applicable factorslistedin rule7.955(b) of the Cal, Rules of Court. Respond toitem 18a(2) on page 7 and
attach a copy ofany writtenattorney fee agreement as Attachment 78a.)
b. The followingadditional 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 ofclaimant's share ofthe proceeds of the settlement or judgment:
Items Payees (names) Amounts
Filing Fees Dalby Wyant, APLC $ 499
Jury Fees Dalby Wyant, APLC $ 150
Process Server Fees Dalby Wyant, APLC $ 65
Medical Records Dalby Wyant, APLC $ 212
File Set Up Fee Dalby Wyant, APLC $ 250
$
$
$
$
$
$
[|__|] Continued on Attachment 14b. Total: $
15. Reimbursement of expenses paid by petitioner
a. Petitionerhas paid none ofthe claimant's expenses listedin items 13 and 14 for which reimbursement is requested.
b. [__] Petitioner has paid (orbecome obligated to pay) the following totalamounts of theclaimant's expenses forwhich
reimbursement is requested.
(1) [-] Medical expenses listedin item 13: $
(2) [__] Attorney's fees included in thetotalfee amount shown in item 74a: $
(3) [__] Other expenses included in thetotal shown initem 14b: $
Total: $ [
(Attach proofs of the expenses incurred and payments made or obligationsto pay incurred, e.g.,billsorinvoices,
canceled checks, credit card statements, explanations of benefitsfrom insurers,etc. )
16. Net balance of proceeds for the claimant
The balance of the proceeds of theproposed settlement or judgment remaining forthe claimant
afterpayment ofall requested fees and expenses is: $| 23,660
17. Summary
a. Gross amount of proceeds of settlement or judgment for claimant: $ 62,500
b. Medical expenses to be paid from proceeds of settlement
or judgment: $ 22,333
c. Attorney's fees to be paid from proceeds of settlement or
judgment: S 15,331
d. Expenses (otherthan medical) to be paid from proceeds
of settlement orjudgment: $ 1,176
é. Total offees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c),and (d)): $ ( 38,840 )
f. Balance of proceeds ofsettlement orjudgment availablefor claimant after payment of all
fees and expenses (subtract (e)from (a)): $ 23,660
MC-$50[Rev.
January
1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page6of10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
CASE MC-350
NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
18. Information about attorney representing or assisting petitioner
a. (1) [| Petitionerhas not been represented orassisted by an attorney inpreparing thispetitionor inany other way with
respectto the claim asserted. (Go to item 19.)
(2) Petitioner has been represented orassisted by an attorney inpreparing thispetitionor with respect to the claim
asserted. Petitioner and the attorney [|] donot do have an agreement forservices provided in
connection withthe claim givingrise tothis petition.(/fyou answered "do,"attach a copy of the agreement as
Attachment 18a, and complete items 18b.—18f )
b. The attorney who has represented orassisted petitioner is(name): Lena L. Dalby
(1) State Bar number: 190207
(2) Lawfirm: Dalby Wyant, APLC
(3) Address: 1013 Galleria Blvd., Suite 275, Roseville, CA 95678
(4) Telephone number: 916-677-2144
c. The attorney hasnot [|] has received attorney'sfees or other compensation in addition tothat requested inthis
petitionfor services provided in connection with the claim giving riseto this petition.
(/f youanswered "has," identifythe person
who paid the fees orother compensation, the amounts paid,and the dates of payment):
From whom (names) Amounts Dates
APPA LS
L__] Continued on Attachment 18c.
d. The attorney didnot [|] did become concerned with thismatter, directlyor indirectly,atthe instance of a party
against whom the claim isasserted or a party's insurance carrier, (ifyou answered "did,"explain the circumstances in
Attachment 18d_)
e. The attorney isnot [| is representing or employed by any other party orany insurance carrierinvolved inthe
matter. (/f youanswered "is,"
identifythe party or carrierand explain the relationship inAttachment 18e.)
f. The attorney does not |__] does expect to receive attorney'sfees or other compensation in addition tothat
requested inthis petitionforservices provided inconnection with the claim giving riseto thispetition.(/f youanswered "does,"
identifythe person who will
pay the fees orother compensation, the amounts tobe paid, and theexpected dates ofpayment):
From whom (names) Amounts Expected dates
©
AH
PAA
L___] Continued on Attachment 18f.
MC-350[Rev.
January1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page7of10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Misceiianeous)
MC-350
CASE NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
19. Disposition of balance of proceeds of settlement or judgment
Petitionerrequests thatthe balance ofthe proceeds of the settlement or judgment be disbursed as follows:
a. [__] There isa guardianship ofthe estate of the minor or a conservatorship ofthe estate of the adult person with a
disabilityfiledin(name of court):
Case no.:
(1) L_] $ ofthe proceeds in money orother property willbe paid ordelivered to
the guardian ofthe estate ofthe minor or the conservator of the estate ofthe conservatee. The money
or other property isspecified inAttachment 19a(1).
(2) [__] Petitioneris the guardian or conservator ofthe estate of the minor or the adult person with a disability.
Petitionerrequests authorityto deposit or invest $ of the money or other
property to be paid or delivered under 19a(1) with one or more financial institutions
in thisstate or with atrust
company, subject towithdrawal only as authorized by the court. The money or other property and the name,
branch, and address ofeach financialinstitutionortrust company are specifiedin Attachment 19a(2).
(3) [__] Petitioner proposes that allor a portion ofthe proceeds not become part ofthe guardianship or
conservatorship estate. Petitioner requests authority todeposit or transfer these proceeds as follows
(check all
that apply):
(a) L_] $ willbe deposited ininsured accounts in one or more financial
institutionsinthis statefrom which no withdrawals can be made without a court order.
The name, branch, and address ofeach depository are specified inAttachment 19a(3).
(b) CL] $ willbe invested in a single-premium deferred annuity subject to
withdrawal only on order ofthe court.The terms and conditions ofthe annuity are specified in
Attachment 19a(3).
(c) [| $ willbe transferred to a custodian forthe benefit of the minor under the
California Uniform Transfers to Minors Act. The name and address of the proposed custodian
and the property to be transferred are specified inAttachment 19a(3).
(d) [__] $ willbe transferred to the trusteeof a trustthat iseithercreated by or
approved of inthe order approving the settlement orthe judgment given orto be given forthe
minor. This trust isrevocable when the minor attains the age of 18 years and contains allother
terms and conditions determined to be necessary by the court to protect the minor's interests.The
terms ofthe proposed trust and the property to be transferred are specifiedin Attachment 19a(3).
[__] A copy of the (proposed) judgment isattached as Attachment 4c.
(e) L_] $ willbe transferred to thetrustee of a special needs trust under
Probate Code sections 3602(d) and 3604 forthe benefit ofthe minor or the adultperson with a
disability.
The terms ofthe proposed special needs trustand the property tobe transferred are
specified inAttachment 19a(3).
MC-$60fRev.
January1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page8 of
10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: Kendall v. Kilgore CASE NUMBER:
SCV0044404
19. Disposition of balance of proceeds of settlement or judgment (cont.)
Petitionerrequests thatthe balance ofthe proceeds of the settlement or judgment be disbursed as follows:
b. There isno guardianship ofthe estate of the minor or conservatorship ofthe estate of the adult person with a disability.
Petitionerrequests thatthe balance ofthe proceeds of the settlement or judgment be disbursed as follows
(check ailthat apply):
(1) [J A guardian of theestate of the minor or a conservator ofthe estate of the adultperson with a disability
willbe appointed. $ of money and otherproperty will be paid or delivered
to the person so appointed. The money or other property are specifiedin Attachment 19b(1).
(2) $ 23,660 of money willbe deposited ininsured accounts inone ormore financial
institutionsinthis state,subject towithdrawal only upon the authorization ofthe court. The name,
branch, and address ofeach depository are specified inAttachment 19b(2).
(3) LJ $ of money willbe invested in a single-premium deferred annuity,subject to
withdrawal only upon the authorization of the court.The terms and conditions of the annuity are specified
inAttachment 19b(3).
4) [J $ willbe paid or transferred tothe trustee of a special needs trust under
Probate Code sections 3604 and 3611(c) forthe benefit ofthe minor orthe adult person with a disability.
The terms of the proposed special needs trustand the money or otherproperty tobe paid ortransferred are
specified inAttachment 19b(4).
$ willbe paid or delivered to a parent ofthe minor, upon the terms and under the
conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the
parent and the money or other property to be delivered are specified inAttachment 19b(5). (Value ofminor's
entire estate,including the money or property to be delivered,must not exceed $5,000. )
$ willbe transferred to a custodian forthe benefitof the minor under theCalifornia
S
Uniform Transfers to Minors Act. The name and address ofthe proposed custodian and the money or other
property to be transferred are specified inAttachment 19b(6).
$ willbe transferred to the trusteeof a trustthat iseither created by or
approved of in theorder approving the settlement orthe judgment given orto be given for the minor. This
trustis revocable when the minor attainsthe age of 18 years and contains allother terms and conditions
determined to be necessary by the court to protectthe minor's interests. The terms ofthe proposed trust and
the money orother property to be transferred are specified inAttachment 19b(7).
LIA copy ofthe (proposed) judgment is attached as Attachment 4c.
$ of money willbe held on such conditions as the court in itsdiscretiondetermines
isin the best interestofthe minor or the adultperson with a disability.
The proposed conditions are specified
on Attachment 196(8). (Value must not exceed $20,000.)
(9) LJ $ of property other than money will be held on such conditions as the court inits
discretion determines isin the bestinterest ofthe minor orthe adult person with a disability.
The proposed
conditions and the property are specified inAttachment 19b(9).
(10) L_] $ willbe deposited with the county treasurer of the County of(name):
The deposit isauthorized under and subject tothe conditions specified in Probate Code section 361 1(h).
(1) CJ $ willbe paid or transferred tothe adult person with a disability.
Preview
MC-350 ATTORNEY ORPARTY WITHOUTATTORNEY(Name,State Barnumber, andaddress): FOR COURTUSE ONLY ena Dalby Pst (SBN 190207) L 1013 Galleria Blvd., Suite 275 ELECTRONICALLY FILED Roseville, CA 95678 Superior Court of California, teLePHone no. (916) 677-2144 FAXNO.(Optional): (916)677-2143 County of Placer E-MAILADDRESS (Optional): 09/25/2020 ATTORNEY FOR(Name): Petitioner, RACHEL KENDALL By: Kathrine Zaragoza, Deputy Clerk SUPERIOR COURT OF CALIFORNIA, COUNTY OF PLACER streetaDDREss: 10820 Justice Center Drive MAILINGADDRESS: cityanpzipcope: Roseville, CA 95678 BrancHName: BillSantucci Justice Center CASE NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 PETITION TO APPROVE: [__] COMPROMISE OF DISPUTED CLAIM HEARINGDATE: COMPROMISE OF PENDING ACTION October 22, 2020 [_] DISPOSITION OF PROCEEDS OF JUDGMENT veer. 42 sme 8:30 a.m. Minor [__] Person With a Disability NOTICE TO PETITIONERS: Except as noted below, you must use thisform to request court approval of(1) the compromise of adisputed claim of a minor, (2) thecompromise ofa pending action or proceeding inwhich a minor or a person with a disability(includinga conservatee) isa party, or(3) the dispositionof the proceeds ofa judgment for a minor or person witha disability.(See Code Civ. Proc.,§ 372: Prob. Code, § 3600 etseq.) You and the minor or disabled person must attend the hearing on thispetition unless the courtfor good caus¢ dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and other evidence relatingto the merits ofthe 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 forapproval ofthe compromises of certain claims and actions or the disposition ofthe proceeds of certainjudgments. Ifyour claim, action, orjudgment qualifiesfor expedited consideration and you want to request you it, must use form MC-350EX foryour request. See Cal. Rules ofCourt, rule 7.950.5. 1. Petitioner (name): RACHEL KENDALL 2. Claimant (name); LAUREN KENDALL, a minor a. Address: 1650 Alblene Circle, Rocklin, CA 95765 b. Date of birth:08/09/05 c. Age: 15 d. Sex: Female e. Minor [__] Person with a disability 3. Relationship Petitioner'srelationshipto the claimant (check ail applicable boxes): a. Parent g. [__] Other relationship (specify:) b. Guardian ad litem c. [__]| Guardian d. [-_] Conservator e. [__] Disabled adultclaimant isa petitioner.(See instructionsforitems 3e and 3f below.) f. (__] Disabled adult claimant's express consent to the relief requested in thispetitionisprovided on Attachment 3f. (if youchecked item 3e or 3f,state factson Attachment 3e or 3fshowing that the claimant has capacity under Probate Code section 812 to petitionorconsent to apetition.Only an adultclaimant who has sufficient capacity and who does not have a conservator ofthe estate may petitionor consent toa petition.See Probate Code section 3613.) 4, Nature of claim The claim of the minor or adult person with a disability: a. [__] Has not been filedin an action orproceeding. (Complete items 5-23.) b. Isthe subject of a pending action or proceeding thatwill be compromised without a trialon the merits ofthe claim. Name ofcourt: Placer County Superior Court Case no.:SCV0044404 Trialdate: None (Complete items 5~23.) Page 1 of10 Altemative Mondatory Use PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ‘°° orobateCode, 2500can Judicial MC-350 Councit [Rev. ofCalifornia January 1, 2011} OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF eval Cal. Rules ofCourt, rules 3.1384, 7.101, 7.950, 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITYo 3 ation Ss (Miscellaneous) “@ Plus MC-350 CASE NAME: Kendail v. Kilgore CASE NUMBER: P SCV0044404 4. Nature of claim The claim ofthe minor or adultperson with a disability: Cc. Isthe subject of a pending action orproceeding that has been orwill be reduced to a judgment for the claimant against the defendants named below inthe total amount (exclusive ofinterest and costs) of (specifybelow): $ [62,500 Defendants (names) Michelle Monier Kilgore [__] Additional defendants listedon Attachment 4. [__] The judgment was filedon (date): (Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.) 5. Incident or accident The incidentor accident occurred as follows: a. Date andtime: March 24, 2018 b. Place: 550 Long Meadow Lane, Lincoln, CA, County of Placer c. Persons involved (names):Lauren Kendall |__| Continued on Attachment 5. 6. [X] Nature of incident or accident The facts,events, and circumstances of the incidentor accident are (describe): Claimant was legally on the premises of Defendant MICHELLE MONIER KILGORE at a sleep over with Defendant's daughter. Defendant KILGORE permitted soap and water to be applied to Defendant's trampoline to use itas a slip and slide. The following morning Claimant and Defendant's daughter returned to the trampoline and began jumping on it. The trampoline had not been appropriately cleaned, and soap remained on the surface of the trampoline making issubstantially more slippery. Claimant began to jump, her feet completely slipped out from under her and she landed awkwardly on her neck. | _] Continued on Attachment 6. 7. Injuries The followinginjurieswere sustained by the claimant as a resultof the incidentor accident (describe): Claimant tore the ligaments in her neck. [__] Continued on Attachment 7. 8. Treatment The claimant received the following care and treatment forthe injuriesdescribed in item 7 (describe): Claimant was seen and evaluated at Sutter Roseville Medical Center and UC Davis Medical Center. She was required to wear a cervical collar and refrain from physical activity while ligaments healed. She then underwent physical therapy to address some residual soreness. [__] Continued on Attachment 8. MC-$50[Rev. January 1,2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page2 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) CASE NAME: Kendall MC-350 v. Kilgore CASE NUMBER: SCV0044404 9. Extent of injuries and recovery (An originalor a photocopy of all doctors‘ reports containing a diagnosis of and prognosis for the claimant'sinjuries,and a report ofthe claimant's present condition, must be attached to thispetitionas Attachment 9. A new report isnot necessary so long as a previous reportaccurately describes the claimant's current condition. ) a. The claimant has recovered completely from the effects ofthe injuriesdescribed initem 7, and there are no permanent injuries. b. [__] The claimant has not recovered completely from the effectsof the injuriesdescribed in item 7, and the following injuries from which the claimant has not recovered are tem porary (describe the remaining injuries): L__] Continued on Attachment 9b. c. [__] The claimant has notrecovered com pletelyfrom the effects ofthe injuriesdescribed initem 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): [__] Continued on Attachment 9c. 10. Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating tothe 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 fullyunderstands that ifthe compromise proposed inthis 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. 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 totalamount offered by alldefendants named below is(specify): $| 62,500 b. The defendants and amounts offered by each are asfollows (specify): Defendants (names) Amounts MICHELLE MONIER KILGORE 62,500 HS FPP SF [__] Defendants and amounts offered continued on Attachment 11. c. The terms of settlement are as follows (ifthe settlement isto be Paid ininstallments, both the totalamount and the present value ofthe settlement must be included): [___] Continued on Attachment 11. MC-350[Rev. January1, 2011} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page3of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Mc-350 CASE NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 12. Settlement payments to others a. [X] No defendant named in item11b has offeredto pay money to any person or persons other than the claimant to settleclaims arisingout of thesame incidentor accident that resulted inthe claimant's injury. b. L By way of settlement, one or more defendants named initem 11b have also offered to pay money toa person or persons other than claimant to settieclaims arisingout of thesame incidentor accident that resulted inthe claimant's injury. (1) The totalamount offered by alldefendants to others (specify): $ (2) Petitioner [| is not [J is aclaimant against the recovery ofthe claimant (otherthan for reimbursement for expenses paid by petitionerand listedunder item 15). (If youanswered "is," explain inAttachment 12 the circumstances and the effectyour claim has on the proposed compromise ofthe claim described inthispetition.) (3) Petitioner [__] isnot [ ]is a plaintiff inthe same actionwith the claimant. (if youanswered "is," explain in Attachment 12 the circumstances and the effectyour claimand itsdisposition has on theproposed compromise of the claimor action described in thispetition. ) (4) [__] Petitionerwould receive money under the proposed settlement. (5) The settlement payments are to be apportioned and distributedas follows: Other plaintiffs or claimants (names) Amounts PAA en $ [] Additional plaintiffs or claimants and amounts are listedon Attachment 12. (6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiffor 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 orjudgment a. Totals (1) Total medical expenses: $ 49,866 (2) Total outstanding medical expenses to be paid from the proceeds: 2 (3) Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds: $ LF b. Medical expenses were paid and are to be reimbursed from proceeds as follows: (1) [__] Paid by petitionerin the amount of: $ LT (2) Paid by private health insurance ora self-funded plan under: (a) [-] An Employee Retirement Income Security Act (ERISA) insured plan. (b) An ERISA self-funded plan. (c) L__] A Non-ERISA insured plan. (d) L_] ANon-ERISA self-funded plan. (e) Amount paid by plan: $ 44,478 (f) Amount of reimbursement to the plan from proceeds of settlement orjudgment: (i) [2] No reimbursement isrequested by the plan. (ii) Reimbursement isto be made to the plan and: (A) L__] There isa contractual reduction of $( ) (B) There isa negotiated reduction of $( 23,645 ) (C) [_] No reduction has been agreed to, for atotal reimbursement tothe plan in the amount of: $ MC-350[Rev, January 1,2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page4of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment b. Medical expenses were paid and are to be reimbursed from proceeds as follows: (3) L-_] Paid by Medicare in the amount of: $ less the statutoryreduction in the amount of: $ ( ) fora total reimbursement toMedicare in the amount of: $ LT (Attach a copy of the finalMedicare demand letterorletteragreement as Attachment 7 36(3).) (4) [__] Paid by Medi-Cal in the amount of $ (a) [__] Notice ofthisclaim or action has been given tothe State Director ofHealth Care Services under Welfare and InstitutionsCode section 14124.73. A copy ofthe notice and proof of itsdelivery [__] is attached. |_] was filedinthismatter on (date): (b) [__] Notice of thisclaim or action has not been given to the State Director ofHealth Care Services. (Explain why noticehas not been given inAttachment 13b(4).) (c) [__] Infullsatisfaction ofitslien rights,Medi-Cal has agreed to accept reimbursement inthe amount of: $ (Attach a copy of the finalMedi-Cal demand /etteror letteragreement as Attachment 1 30(4).) (a) L_] Petitioner isentitledto a reduction ofthe Medi-Cal lienunder Welfare and InstitutionsCode section 14124.76 ana: (i)[J Isfilinga motion seeking a reduction of the lienconcurrently with this petition. (ii)(__] Requests that the court reserve jurisdictionover thisissue. The amount of the lienindispute is:$ (5) (a) There are one or more statutoryor contractual liens ofmedical service providers for payment of medical expenses. The total amount claimed under these liensis: $ 49 601 __!n full satisfaction of theirlienclaims, the lienholders have agreed to accept the totalsum of: $ 22,333 (Provide requested information on each lienholder and certain other medical service providers below. ) (b) The name of each medical service provider thatfurnished care and treatment to claimant and (1)has a lienforall or any part ofthe charges or (2)was paid (or willbe paid from the proceeds) by petitionerfor which petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reduction ofcharges, ifany; and the amount to be paid from the proceeds of thesettlement orjudgment to each provider are as follows: (i) (A) Provider (name): UMR (ERISA self-funded plan) (B) Address: L-3994, Columbus, OH 43260-3994 (C) Amount charged: $ 44,478 (D) Amount paid (whether or not by insurance): $ ( ) (E) )Negotiated reduction, ifany: $( 23,645 ) ( F) Amount tobe paidfrom proceeds of settlement or judgment: $ 20,833 (ii)(A) Provider (name): Health Advocates (for UC Davis Medical Center) (B) Address: 21540 Plummer Street, Suite B, Chatsworth, CA 91311 (C) Amount charged: $ 5,123 (D} Amount paid (whether or not by insurance): $( ) (E) Negotiated reduction, if any: $( 3,623 ) (F) Amount to be paid from proceeds of settlement or judgment: $ |] Continued on Attachment 13b(5). (Provide information about additionalproviders in theabove format. includingproviders paid orto be paid by petitioner forwhich reimbursement isrequested initem 13b(1) above. You may use form MC-350(A-13b(5)) forthis purpose.) MC-350[Rev. January4, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page5of10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MiC-350 CASE NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 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 tobe reimbursed from proceeds of settlement or judgment a. Total amount of attorney'sfees for which courtapproval isrequested: $ 15,331 (iffees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis forthe request, including a discussion of applicable factorslistedin rule7.955(b) of the Cal, Rules of Court. Respond toitem 18a(2) on page 7 and attach a copy ofany writtenattorney fee agreement as Attachment 78a.) b. The followingadditional 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 ofclaimant's share ofthe proceeds of the settlement or judgment: Items Payees (names) Amounts Filing Fees Dalby Wyant, APLC $ 499 Jury Fees Dalby Wyant, APLC $ 150 Process Server Fees Dalby Wyant, APLC $ 65 Medical Records Dalby Wyant, APLC $ 212 File Set Up Fee Dalby Wyant, APLC $ 250 $ $ $ $ $ $ [|__|] Continued on Attachment 14b. Total: $ 15. Reimbursement of expenses paid by petitioner a. Petitionerhas paid none ofthe claimant's expenses listedin items 13 and 14 for which reimbursement is requested. b. [__] Petitioner has paid (orbecome obligated to pay) the following totalamounts of theclaimant's expenses forwhich reimbursement is requested. (1) [-] Medical expenses listedin item 13: $ (2) [__] Attorney's fees included in thetotalfee amount shown in item 74a: $ (3) [__] Other expenses included in thetotal shown initem 14b: $ Total: $ [ (Attach proofs of the expenses incurred and payments made or obligationsto pay incurred, e.g.,billsorinvoices, canceled checks, credit card statements, explanations of benefitsfrom insurers,etc. ) 16. Net balance of proceeds for the claimant The balance of the proceeds of theproposed settlement or judgment remaining forthe claimant afterpayment ofall requested fees and expenses is: $| 23,660 17. Summary a. Gross amount of proceeds of settlement or judgment for claimant: $ 62,500 b. Medical expenses to be paid from proceeds of settlement or judgment: $ 22,333 c. Attorney's fees to be paid from proceeds of settlement or judgment: S 15,331 d. Expenses (otherthan medical) to be paid from proceeds of settlement orjudgment: $ 1,176 é. Total offees and expenses to be paid from proceeds of settlement or judgment (add (b), (c),and (d)): $ ( 38,840 ) f. Balance of proceeds ofsettlement orjudgment availablefor claimant after payment of all fees and expenses (subtract (e)from (a)): $ 23,660 MC-$50[Rev. January 1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page6of10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) CASE MC-350 NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 18. Information about attorney representing or assisting petitioner a. (1) [| Petitionerhas not been represented orassisted by an attorney inpreparing thispetitionor inany other way with respectto the claim asserted. (Go to item 19.) (2) Petitioner has been represented orassisted by an attorney inpreparing thispetitionor with respect to the claim asserted. Petitioner and the attorney [|] donot do have an agreement forservices provided in connection withthe claim givingrise tothis petition.(/fyou answered "do,"attach a copy of the agreement as Attachment 18a, and complete items 18b.—18f ) b. The attorney who has represented orassisted petitioner is(name): Lena L. Dalby (1) State Bar number: 190207 (2) Lawfirm: Dalby Wyant, APLC (3) Address: 1013 Galleria Blvd., Suite 275, Roseville, CA 95678 (4) Telephone number: 916-677-2144 c. The attorney hasnot [|] has received attorney'sfees or other compensation in addition tothat requested inthis petitionfor services provided in connection with the claim giving riseto this petition. (/f youanswered "has," identifythe person who paid the fees orother compensation, the amounts paid,and the dates of payment): From whom (names) Amounts Dates APPA LS L__] Continued on Attachment 18c. d. The attorney didnot [|] did become concerned with thismatter, directlyor indirectly,atthe instance of a party against whom the claim isasserted or a party's insurance carrier, (ifyou answered "did,"explain the circumstances in Attachment 18d_) e. The attorney isnot [| is representing or employed by any other party orany insurance carrierinvolved inthe matter. (/f youanswered "is," identifythe party or carrierand explain the relationship inAttachment 18e.) f. The attorney does not |__] does expect to receive attorney'sfees or other compensation in addition tothat requested inthis petitionforservices provided inconnection with the claim giving riseto thispetition.(/f youanswered "does," identifythe person who will pay the fees orother compensation, the amounts tobe paid, and theexpected dates ofpayment): From whom (names) Amounts Expected dates © AH PAA L___] Continued on Attachment 18f. MC-350[Rev. January1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page7of10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Misceiianeous) MC-350 CASE NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 19. Disposition of balance of proceeds of settlement or judgment Petitionerrequests thatthe balance ofthe proceeds of the settlement or judgment be disbursed as follows: a. [__] There isa guardianship ofthe estate of the minor or a conservatorship ofthe estate of the adult person with a disabilityfiledin(name of court): Case no.: (1) L_] $ ofthe proceeds in money orother property willbe paid ordelivered to the guardian ofthe estate ofthe minor or the conservator of the estate ofthe conservatee. The money or other property isspecified inAttachment 19a(1). (2) [__] Petitioneris the guardian or conservator ofthe estate of the minor or the adult person with a disability. Petitionerrequests authorityto deposit or invest $ of the money or other property to be paid or delivered under 19a(1) with one or more financial institutions in thisstate or with atrust company, subject towithdrawal only as authorized by the court. The money or other property and the name, branch, and address ofeach financialinstitutionortrust company are specifiedin Attachment 19a(2). (3) [__] Petitioner proposes that allor a portion ofthe proceeds not become part ofthe guardianship or conservatorship estate. Petitioner requests authority todeposit or transfer these proceeds as follows (check all that apply): (a) L_] $ willbe deposited ininsured accounts in one or more financial institutionsinthis statefrom which no withdrawals can be made without a court order. The name, branch, and address ofeach depository are specified inAttachment 19a(3). (b) CL] $ willbe invested in a single-premium deferred annuity subject to withdrawal only on order ofthe court.The terms and conditions ofthe annuity are specified in Attachment 19a(3). (c) [| $ willbe transferred to a custodian forthe benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are specified inAttachment 19a(3). (d) [__] $ willbe transferred to the trusteeof a trustthat iseithercreated by or approved of inthe order approving the settlement orthe judgment given orto be given forthe minor. This trust isrevocable when the minor attains the age of 18 years and contains allother terms and conditions determined to be necessary by the court to protect the minor's interests.The terms ofthe proposed trust and the property to be transferred are specifiedin Attachment 19a(3). [__] A copy of the (proposed) judgment isattached as Attachment 4c. (e) L_] $ willbe transferred to thetrustee of a special needs trust under Probate Code sections 3602(d) and 3604 forthe benefit ofthe minor or the adultperson with a disability. The terms ofthe proposed special needs trustand the property tobe transferred are specified inAttachment 19a(3). MC-$60fRev. January1, 2011] PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page8 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: Kendall v. Kilgore CASE NUMBER: SCV0044404 19. Disposition of balance of proceeds of settlement or judgment (cont.) Petitionerrequests thatthe balance ofthe proceeds of the settlement or judgment be disbursed as follows: b. There isno guardianship ofthe estate of the minor or conservatorship ofthe estate of the adult person with a disability. Petitionerrequests thatthe balance ofthe proceeds of the settlement or judgment be disbursed as follows (check ailthat apply): (1) [J A guardian of theestate of the minor or a conservator ofthe estate of the adultperson with a disability willbe appointed. $ of money and otherproperty will be paid or delivered to the person so appointed. The money or other property are specifiedin Attachment 19b(1). (2) $ 23,660 of money willbe deposited ininsured accounts inone ormore financial institutionsinthis state,subject towithdrawal only upon the authorization ofthe court. The name, branch, and address ofeach depository are specified inAttachment 19b(2). (3) LJ $ of money willbe invested in a single-premium deferred annuity,subject to withdrawal only upon the authorization of the court.The terms and conditions of the annuity are specified inAttachment 19b(3). 4) [J $ willbe paid or transferred tothe trustee of a special needs trust under Probate Code sections 3604 and 3611(c) forthe benefit ofthe minor orthe adult person with a disability. The terms of the proposed special needs trustand the money or otherproperty tobe paid ortransferred are specified inAttachment 19b(4). $ willbe paid or delivered to a parent ofthe minor, upon the terms and under the conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the parent and the money or other property to be delivered are specified inAttachment 19b(5). (Value ofminor's entire estate,including the money or property to be delivered,must not exceed $5,000. ) $ willbe transferred to a custodian forthe benefitof the minor under theCalifornia S Uniform Transfers to Minors Act. The name and address ofthe proposed custodian and the money or other property to be transferred are specified inAttachment 19b(6). $ willbe transferred to the trusteeof a trustthat iseither created by or approved of in theorder approving the settlement orthe judgment given orto be given for the minor. This trustis revocable when the minor attainsthe age of 18 years and contains allother terms and conditions determined to be necessary by the court to protectthe minor's interests. The terms ofthe proposed trust and the money orother property to be transferred are specified inAttachment 19b(7). LIA copy ofthe (proposed) judgment is attached as Attachment 4c. $ of money willbe held on such conditions as the court in itsdiscretiondetermines isin the best interestofthe minor or the adultperson with a disability. The proposed conditions are specified on Attachment 196(8). (Value must not exceed $20,000.) (9) LJ $ of property other than money will be held on such conditions as the court inits discretion determines isin the bestinterest ofthe minor orthe adult person with a disability. The proposed conditions and the property are specified inAttachment 19b(9). (10) L_] $ willbe deposited with the county treasurer of the County of(name): The deposit isauthorized under and subject tothe conditions specified in Probate Code section 361 1(h). (1) CJ $ willbe paid or transferred tothe adult person with a disability.