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ELEVENTH JUDICIAL CIRCUIT COURT McLEAN COUNTY, IL In the Matter of the Estate of } } , } A Minor } Case Number: } PETITION TO SETTLE CAUSE OF ACTION – MINOR’S ESTATE , guardian of the estate of , a minor, on oath states: 1. The minor has a cause of action against for injury to him on , , by reason of (briefly describe accident): 2. The injuries were: 3. The minor was treated at hospital and attended by Dr. , whose certificate is attached. 4. Suit been filed as Case Number in (has or has not) 5. A settlement of $ has been offered and petitioner recommends that it be accepted. 6. The charges against the proceeds are: For hospitalization $ For medical treatment For medical treatment For medical treatment For court costs For bond premium For For For legal services of settlement) (Next Page) ---PAGE BREAK--- For attorney’s disbursements (itemize) for $ for for for Total $ 7. A reasonable amount to be paid to (Name of guardian, Parent or Relative. State Relationship) for the benefit of the minor is $ . 8. is a qualified depository for $ The balance of the settlement proceeds to be held in the account for the minor until he reaches majority on , , or until further order of court. Petitioner asks leave to settle the cause of action for the sum offered, to distribute the proceeds and to be discharged as guardian. Signed and sworn to before me Signature of Guardian , . (Notary Public) CERTIFICATE OF ATTORNEY I certify that I have examined the facts of this case and the applicable law and in my opinion the proposed settlement is just and proper and that my disbursements were necessary and reasonable. (Attorney) Name Attorney for Petitioner Address City Telephone