Preview
MC~351
ATTORNEY OR PARTY WITHOUT
ATTORNEY
(Name, State Bar number, and address): FOR COURT USE ONLY
Ay
Mark BE, Ellis - 127159
Bric T. Goodman - 322954
02
Ellis Law Group, LLP
NB(2Orene0
1425 River Park Drive, Suite 400
Sacramento, CA 95815 . FILE lifornia
TELEPHONE
NO: 916-283-8820 FAX NO. (Optional): 916-283-8821
Supervunty of Placerorn
E-MAIL ADDRESS
(Optional):
h -ATTORNEYFOR
(Name:
Plaintiffs JORDYN DeALVA, a minor child AUG o7 2020
‘ SUPERIOR
COURT OF CALIFORNIA,
COUNTY OF Placer
Received
streeraporess:
10820 Justice Center Drive Jake Chatters
, MAILING ADDRESS: ExecutiveOfficer or
ciyann zipcope:
Roseville, CA 95678 By: M.Taylor,De
BRANCH
NAME:
Bill Santucci Justice Center
¢ CASENAME:JORDYN
DeALVA,a minor
child, through
her mother
and Guardian
ad Litem, Nancy
DeAlva
clronically
py. ROSEVILLE
CITYSCHOOL DISTRICT
bDORDER APPROVING: CASE NUMBER:
F(__] COMPROMISE OF DISPUTED CLAIM S-CV-0041154
{x |] COMPROMISE OF PENDING ACTION
[__] DISPOSITION OF PROCEEDS OF JUDGMENT HEARING
DATE, IF ANY:
DEPT.:
[_] Minor [__]PersonWitha Disability
1. Petitioner
(name):
Nancy DeAlva haspetitioned
for court
approval
of a
proposed
compromiseof a disputed
claimof a
minorora pending
action
involving
a minor‘or
a person
witha disability
or a
proposed
disposition
of the
proceeds
of a judgment
for
a minor
ora person
with
a disability.
2. Hearing .
a. [__] No hearing
washeld.
The petition
is an
expedited
petition
underrule
7.950.5
of the
California
Rules
of Court.
b. Date:08/27/2020 Time:8: 30am Dept.:
42
c.Judicial
officerr-Judge
Charles Wachob
3. Relationship
toclaimant
Petitioner
hasthefollowina
relationship
orrelationshios
to claimant
(check
all applicable
boxes):
a. LX 1 Parent
b. Guardian
ad litem
c. [_] Guardian
d. [__] Conservator
e. C4 Claimant,
anadult
personwith
a disability,
is the
petitioner.
f. (_] Other(specify):
4. Claimant(name):
Jordyn DeAlva
a. isa minor.
b. [__] isa"person
witha disability"
within
themeaningof Probate
Code section
3603whois:
(1)[._] Anadult.
Claimant's
dateof birth
is (specify):
(a){__]Without
a conservator.
Claimant
hascapacity
toconsentto
thisorder,
within
themeaningof
Probate
Code section
812,andhasconsented
to this
order.
(b)[_] A conservatee;
apersonfor whom
a conservator
maybe appointed;
or without
capacity
to
consent
to this
order,
within
themeaningof Probate
Codesection
812.
(2){__] Aminordescribed
inProbate
Code section
3603(b)(3).
5. Defendant
Theclaimor action
tobecompromisedis asserted,
or the
judgmentis entered,
against
(nameof settling
or judgment
defendant
or
defendants
(the
"payer")):
ROSEVILLE CITY SCHOOL DISTRICT
Page 1 of 4
Form
Adopted for Handatoyuse
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Code
o ivi Procedure § 372
Mc-351
[Rev.
January 1, 2010]
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR cat rules ot cout
rules3.1384, 7.098
MINOR OR PERSON
; WITH A DISABILITY
(Miscellaneous) olutiqns:
feDus
Mc--351
CASENAME:JORDYNDeALVA,
a minor child, through
her mother and Guardian
ad Litem, NancyCASE NUMBER:
DeAlva v. ROSEVILLE
CITYSCHOOLDISTRICT S-CV-0041154
6. THE COURT FINDSthat
all notices
required
bylaw
havebeengiven.
7. THE COURT ORDERS
a_Thepetition
is granted
andthe
proposedcompromise
of claim
or action
or the
proposed
disposition
of the
proceeds
of the
judgment
is approved.
Thegrossamount
or value
of the
settlement
or judgment
in favor of claimant
is $
| 350,000.00
b [-"] Until
further
order
of the
court,
jurisdiction
is reserved
to determine
a claim
for a
reduction
of a Medi-Cal
lien
under
Welfare
andInstitutions
Codesection
14124.76.
Theamountshownpayable
to the
Department
of Health
CareServices
in item
7c(1)(d)
of this
orderis the
full amount
of the
lien claimed
bythe
department
butis subject
toreduction
onfurther
order
of the
court
upondetermination
of the
claim
for reduction.
c Thepayershall!
disburse
theproceeds
of the
settlement
or judgment
approved
bythis
orderin the
following
manner:
(i) Paymentof fees
andexpenses
Feesandexpensesshall
bepaid
byone or more
checks
or drafts,
drawnpayable
to the
order
of the
petitioner
andthe
petitioner's
attorney,
if any,
or directly
to third
parties
entitled
to receive
paymentidentified in this
order
for the
following
items
of expense
or damage,
whicharehereby
authorized
tobepaidout
of the
proceeds
of the
settlement
or judgment:
(a) Attorney's
feesin the
total
amountof:
$ 72,193.93 payable
to(specify):
EllisLaw Group,
LLP
(b) Reimbursement
for medical
andallother
expenses
paid
by the
petitioner
or the 13.206.07
petitioner's
attorney
in the
total
amountof: $
(c)EX] Medical,
hospital,
ambulance,
nursing,
andother
like
expenses
payable
directly
to
providers
asfollows,
in the
total
amountof: $ {64,600.00
(i)
Payee(name):
Equian
(A)Address:P.O, Box 36380,Louisville,
Kentucky40233
(B)Amount:$60,000.00
(ii)
Payee(name):
Concussion MedicalClinic(Dr.AshutoshRaina)
1A)Madress: 3800 StanfordRancnKoga #800,Rockin, Caltornia93705
(B)Amount:$4,600.00
[-] Continued
onAttachment
7c(1)(c).
(Provide
information
about
additional payees
in the
aboveformat.)
(d)[__] Other
authorized
disbursements
payable
directly
to third
parties
in the
total
amount
of:$0.00
(Describe
andstate
theamountof each
item
and provide
thenameandaddressof each
payee):
{_] Continued
onAttachment
7c(1)(d).
(e) Total
allowance
for fees
and expenses
fromthe
settlement
or judgment: $ |150,000.00
MC-351 [Rev,
January 1, 2010]
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Page
2 of 4
ACTION OR DISPOSITIONOF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC~361
|CASENAME:JORDYNDeALVA,
a minor child, through her mother and Guardian ad Litem, Nancy
CASE NUMBER:
DeAlva
v. ROSEVILLE
CITYSCHOOLDISTRICT S-CV-0041154
7. THE COURT ORDERS (cont.)
c. Thepayershall
disburse
theproceeds
of the
settlement
or judgment
approvedbythis
order
in the
following
manner:
(2)Balance
Thebalance
of the
settlement
or judgment
available
for claimant
after payment
of all allowed
fees
and expenses
is: ${200,000.00
Thebalance
shall
be disbursed
as follows:
(a)[__]Byone ormorechecks
or drafts
in the total
amountof (specify):
$ 0.00
drawnpayable
to the
order
of the
petitioner
astrustee
for the
claimant.
Eachsuchcheckor draft
mustbearan
endorsement
onthefaceor reverse
that
it is for deposit
in one
or more
interest-bearing,
federally
insured
accounts
in the
name of the
petitioner
as trustee
for the
claimant,
andnowithdrawals
may bemadefromthe
accounts
except
asprovided
in the
Orderto Deposit
ManeyInto
Blocked
Account(form
MC-355),
whichis
signed
contemporaneously
with
this
order
("blocked
account").
(b) Bythefollowing
method(s)
(describe
eachmethod,
including
the
amount to be
disbursed
):
By check made out as follows: ;
lL.
(i-iii) The amount
of $195,000.00
payable to USAA
Annuity Services Corporation
as detailed within Attachment
7c(2)(b).
2.(i) PAYEE:
Nancy
DeAlva,
as a custodian for Jordyn DeAlva
under the California Uniform
Transfers to Minors
Act.
(ii) ADDRESS:
8161
Ramwood
Way,
Orangevale, CA
95662
(iii) AMOUNT:
$5,000.00
Continued
onAttachment
7¢(2)(b).
(c)[__]If money
is to be
paidto a special
needstrust under
Probate
Code section
3604,all statutory
liens
in favor
of the
state
Department
of Health
CareServices,
thestate
Department
of Mental
Health,
the
state
Department
of Developmental
Services,
andanycity and
county
inCalifornia
must
first be
satisfied
bythe
following
method(specify);
[] Continued
onAttachment
7c(2)(c).
8.[__] Further
ordersof the
courtconcerning
blocked
accounts
Thecourt
makes the
following
additional
orders
concerning
anypart
of the
balance
ordered
to be
deposited
in a blocked
account
underitem
7c(2)(a):
a. Within
48hoursof receipt
of a check
or draft described
in item
7c(2)(a),
the
petitioner
and the
petitioner's
attorney,
if
any,mustdeposit
thecheckor draft
in the
petitioner's
nameas trustee
for the
claimant
in one
or moreblocked
accounts
at (specify
name,branch,
andaddress
of each
depository,
andtheamountof each
account):
[-] Continued
onAttachment
8a.
MC-351 [Rev,
January 1,201]
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Page
3 of 4
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-351
CASENAME: JORDYN
DeALVA,
a minor child, through
her mother and Guardian
ad Litem, Nancy CASE NUMBER:
DeAlva y. ROSEVILLE
CITYSCHOOLDISTRICT S~-CV-0041154
8. Further
ordersof the
court
concerning
blockedaccounts
Thecourt
makes the
following
additional
orders
concerning
anypart
of the
balanceordered
to be
deposited
in a blocked
account
underitem
7c(2)(a):
b. Thepetitioner
andthe
petitioner's
attorney,
if any,
mustdeliver
to each
depository
at the
timeof deposit
three
copiesof
theOrder
to Deposit
MoneyIntoBlocked
Account
(form
MC-355),
which is signed
contemporaneously
withthis
order,
andthree
copiesof the
Receipt
andAcknowledgment
of Order for the
Deposit
of Money
Into
BlockedAccount
(form
MC-356).
The petitioner
or the
petitioner's
attorney
mustfile a copy
of the
receipt
with
this
court
within
15daysof the
deposit.
Thesoleresponsibilities
of the
petitioner
andthe
petitioner's
attorney,
if any,
aretoplace
thebalance
ina
blocked
account
or accounts
andto timely
file a copy
of the
receipt.
c.Thebalanceof the
proceeds
of the
settlement
or judgment
deposited
in a blocked
account
oraccounts
underitem
7c(2)(a)
may be withdrawn
only
asfollows
(check
(1) or (2)):
(1) [£2]No withdrawals
of principal
orinterest
may bemade from
theblocked
account
or accounts
without
a further
written
orderunder
this
casenameand number,
signed
bya judge,
andbearing
the
seal of this court.
The
moneyon deposit is not
subject
to escheat.
(2) {__]Theblocked
account
or accounts
belongto a minor.
Theminor
was born
on (date): .
Nowithdrawals
of principal
or interest
may bemadefromtheblocked
account
or accounts
without
a further
written
orderunder
this
casenameand number,
signed
by a
judicial
officer,
and bearing
thesealof this
-
court,
until
theminor
attains
theageof 18
years.
When the
minorattains
theageof 18
years,
thedepository,
without
further
order
of this
court,
Preview
MC~351 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY Ay Mark BE, Ellis - 127159 Bric T. Goodman - 322954 02 Ellis Law Group, LLP NB(2Orene0 1425 River Park Drive, Suite 400 Sacramento, CA 95815 . FILE lifornia TELEPHONE NO: 916-283-8820 FAX NO. (Optional): 916-283-8821 Supervunty of Placerorn E-MAIL ADDRESS (Optional): h -ATTORNEYFOR (Name: Plaintiffs JORDYN DeALVA, a minor child AUG o7 2020 ‘ SUPERIOR COURT OF CALIFORNIA, COUNTY OF Placer Received streeraporess: 10820 Justice Center Drive Jake Chatters , MAILING ADDRESS: ExecutiveOfficer or ciyann zipcope: Roseville, CA 95678 By: M.Taylor,De BRANCH NAME: Bill Santucci Justice Center ¢ CASENAME:JORDYN DeALVA,a minor child, through her mother and Guardian ad Litem, Nancy DeAlva clronically py. ROSEVILLE CITYSCHOOL DISTRICT bDORDER APPROVING: CASE NUMBER: F(__] COMPROMISE OF DISPUTED CLAIM S-CV-0041154 {x |] COMPROMISE OF PENDING ACTION [__] DISPOSITION OF PROCEEDS OF JUDGMENT HEARING DATE, IF ANY: DEPT.: [_] Minor [__]PersonWitha Disability 1. Petitioner (name): Nancy DeAlva haspetitioned for court approval of a proposed compromiseof a disputed claimof a minorora pending action involving a minor‘or a person witha disability or a proposed disposition of the proceeds of a judgment for a minor ora person with a disability. 2. Hearing . a. [__] No hearing washeld. The petition is an expedited petition underrule 7.950.5 of the California Rules of Court. b. Date:08/27/2020 Time:8: 30am Dept.: 42 c.Judicial officerr-Judge Charles Wachob 3. Relationship toclaimant Petitioner hasthefollowina relationship orrelationshios to claimant (check all applicable boxes): a. LX 1 Parent b. Guardian ad litem c. [_] Guardian d. [__] Conservator e. C4 Claimant, anadult personwith a disability, is the petitioner. f. (_] Other(specify): 4. Claimant(name): Jordyn DeAlva a. isa minor. b. [__] isa"person witha disability" within themeaningof Probate Code section 3603whois: (1)[._] Anadult. Claimant's dateof birth is (specify): (a){__]Without a conservator. Claimant hascapacity toconsentto thisorder, within themeaningof Probate Code section 812,andhasconsented to this order. (b)[_] A conservatee; apersonfor whom a conservator maybe appointed; or without capacity to consent to this order, within themeaningof Probate Codesection 812. (2){__] Aminordescribed inProbate Code section 3603(b)(3). 5. Defendant Theclaimor action tobecompromisedis asserted, or the judgmentis entered, against (nameof settling or judgment defendant or defendants (the "payer")): ROSEVILLE CITY SCHOOL DISTRICT Page 1 of 4 Form Adopted for Handatoyuse ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Code o ivi Procedure § 372 Mc-351 [Rev. January 1, 2010] ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR cat rules ot cout rules3.1384, 7.098 MINOR OR PERSON ; WITH A DISABILITY (Miscellaneous) olutiqns: feDus Mc--351 CASENAME:JORDYNDeALVA, a minor child, through her mother and Guardian ad Litem, NancyCASE NUMBER: DeAlva v. ROSEVILLE CITYSCHOOLDISTRICT S-CV-0041154 6. THE COURT FINDSthat all notices required bylaw havebeengiven. 7. THE COURT ORDERS a_Thepetition is granted andthe proposedcompromise of claim or action or the proposed disposition of the proceeds of the judgment is approved. Thegrossamount or value of the settlement or judgment in favor of claimant is $ | 350,000.00 b [-"] Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under Welfare andInstitutions Codesection 14124.76. Theamountshownpayable to the Department of Health CareServices in item 7c(1)(d) of this orderis the full amount of the lien claimed bythe department butis subject toreduction onfurther order of the court upondetermination of the claim for reduction. c Thepayershall! disburse theproceeds of the settlement or judgment approved bythis orderin the following manner: (i) Paymentof fees andexpenses Feesandexpensesshall bepaid byone or more checks or drafts, drawnpayable to the order of the petitioner andthe petitioner's attorney, if any, or directly to third parties entitled to receive paymentidentified in this order for the following items of expense or damage, whicharehereby authorized tobepaidout of the proceeds of the settlement or judgment: (a) Attorney's feesin the total amountof: $ 72,193.93 payable to(specify): EllisLaw Group, LLP (b) Reimbursement for medical andallother expenses paid by the petitioner or the 13.206.07 petitioner's attorney in the total amountof: $ (c)EX] Medical, hospital, ambulance, nursing, andother like expenses payable directly to providers asfollows, in the total amountof: $ {64,600.00 (i) Payee(name): Equian (A)Address:P.O, Box 36380,Louisville, Kentucky40233 (B)Amount:$60,000.00 (ii) Payee(name): Concussion MedicalClinic(Dr.AshutoshRaina) 1A)Madress: 3800 StanfordRancnKoga #800,Rockin, Caltornia93705 (B)Amount:$4,600.00 [-] Continued onAttachment 7c(1)(c). (Provide information about additional payees in the aboveformat.) (d)[__] Other authorized disbursements payable directly to third parties in the total amount of:$0.00 (Describe andstate theamountof each item and provide thenameandaddressof each payee): {_] Continued onAttachment 7c(1)(d). (e) Total allowance for fees and expenses fromthe settlement or judgment: $ |150,000.00 MC-351 [Rev, January 1, 2010] ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Page 2 of 4 ACTION OR DISPOSITIONOF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC~361 |CASENAME:JORDYNDeALVA, a minor child, through her mother and Guardian ad Litem, Nancy CASE NUMBER: DeAlva v. ROSEVILLE CITYSCHOOLDISTRICT S-CV-0041154 7. THE COURT ORDERS (cont.) c. Thepayershall disburse theproceeds of the settlement or judgment approvedbythis order in the following manner: (2)Balance Thebalance of the settlement or judgment available for claimant after payment of all allowed fees and expenses is: ${200,000.00 Thebalance shall be disbursed as follows: (a)[__]Byone ormorechecks or drafts in the total amountof (specify): $ 0.00 drawnpayable to the order of the petitioner astrustee for the claimant. Eachsuchcheckor draft mustbearan endorsement onthefaceor reverse that it is for deposit in one or more interest-bearing, federally insured accounts in the name of the petitioner as trustee for the claimant, andnowithdrawals may bemadefromthe accounts except asprovided in the Orderto Deposit ManeyInto Blocked Account(form MC-355), whichis signed contemporaneously with this order ("blocked account"). (b) Bythefollowing method(s) (describe eachmethod, including the amount to be disbursed ): By check made out as follows: ; lL. (i-iii) The amount of $195,000.00 payable to USAA Annuity Services Corporation as detailed within Attachment 7c(2)(b). 2.(i) PAYEE: Nancy DeAlva, as a custodian for Jordyn DeAlva under the California Uniform Transfers to Minors Act. (ii) ADDRESS: 8161 Ramwood Way, Orangevale, CA 95662 (iii) AMOUNT: $5,000.00 Continued onAttachment 7¢(2)(b). (c)[__]If money is to be paidto a special needstrust under Probate Code section 3604,all statutory liens in favor of the state Department of Health CareServices, thestate Department of Mental Health, the state Department of Developmental Services, andanycity and county inCalifornia must first be satisfied bythe following method(specify); [] Continued onAttachment 7c(2)(c). 8.[__] Further ordersof the courtconcerning blocked accounts Thecourt makes the following additional orders concerning anypart of the balance ordered to be deposited in a blocked account underitem 7c(2)(a): a. Within 48hoursof receipt of a check or draft described in item 7c(2)(a), the petitioner and the petitioner's attorney, if any,mustdeposit thecheckor draft in the petitioner's nameas trustee for the claimant in one or moreblocked accounts at (specify name,branch, andaddress of each depository, andtheamountof each account): [-] Continued onAttachment 8a. MC-351 [Rev, January 1,201] ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING Page 3 of 4 ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-351 CASENAME: JORDYN DeALVA, a minor child, through her mother and Guardian ad Litem, Nancy CASE NUMBER: DeAlva y. ROSEVILLE CITYSCHOOLDISTRICT S~-CV-0041154 8. Further ordersof the court concerning blockedaccounts Thecourt makes the following additional orders concerning anypart of the balanceordered to be deposited in a blocked account underitem 7c(2)(a): b. Thepetitioner andthe petitioner's attorney, if any, mustdeliver to each depository at the timeof deposit three copiesof theOrder to Deposit MoneyIntoBlocked Account (form MC-355), which is signed contemporaneously withthis order, andthree copiesof the Receipt andAcknowledgment of Order for the Deposit of Money Into BlockedAccount (form MC-356). The petitioner or the petitioner's attorney mustfile a copy of the receipt with this court within 15daysof the deposit. Thesoleresponsibilities of the petitioner andthe petitioner's attorney, if any, aretoplace thebalance ina blocked account or accounts andto timely file a copy of the receipt. c.Thebalanceof the proceeds of the settlement or judgment deposited in a blocked account oraccounts underitem 7c(2)(a) may be withdrawn only asfollows (check (1) or (2)): (1) [£2]No withdrawals of principal orinterest may bemade from theblocked account or accounts without a further written orderunder this casenameand number, signed bya judge, andbearing the seal of this court. The moneyon deposit is not subject to escheat. (2) {__]Theblocked account or accounts belongto a minor. Theminor was born on (date): . Nowithdrawals of principal or interest may bemadefromtheblocked account or accounts without a further written orderunder this casenameand number, signed by a judicial officer, and bearing thesealof this - court, until theminor attains theageof 18 years. When the minorattains theageof 18 years, thedepository, without further order of this court,