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MC-350EX
ATTORNEY OR PARTY WITHOUT ATTORNEY ‘STATE BAR NUMBER: FOR COURT USE ONLY
NAME: ELIZABETH S. CARLSEN, SBN 270293
FIRM NAME: BATES WINTER TALMACHOFF VANDERSLUYS LLP
‘STREET ADDRESS: 925 HIGHLAND POINT DRIVE, STE. 380
city: ROSEVILLE sTaTe: CA ZIPCODE: 95678
ELECTRONICALLY FILED
uperior Court of California
‘TELEPHONE NO, 916-789-7080 FAXNO.: 916-789-7090 ounty of Sacramento
EMAILADDRESS:ecarlsen@bateswinterlaw.com
03/08/2024
ATTORNEY FOR (Name):
Rodne Stevens
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO By: T. Crowther Dey uty
‘STREET ADDRESS: 720 Ninth Street
MAILING ADDRESS: SAME
CITY AND ZIP CODE: Sacramento, California 95814
BRANCH NAME: Gordon D. Schaber Courthouse
CASE NAME: CASE NUMBER:
IN RE: ASHLYNN RIBLETT 24cyv0044531
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
[XNo hearing date is requested.
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF Cdearine vate:
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
DEPT. TIME:
NOTICE TO PETITIONER
!You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) compromise
lof a pending action or proceeding in which a minor ora person with a disability (including a conservatee) is a party, or (3) disposition of
the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) You
Imay request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and
either 3g(1) or 3g(2), below, are true and accurate; and (3) the court does not otherwise order.
If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a
hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise
or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or
Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing.
1 Petitioner (name or pseudonym’). CARL RIBLETT_ (See Attachment 1)
is the (check all boxes that apply): (Parent [Guardian ad litem* CQcuardian Clconservator
(other (specify relationship):
of the claimant identified in item 2. (“Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that
pseudonym. (See Code Civ. Proc., § 372.5.))
Claimant (name): ASHLYNN RIBLETT, a minor
a. Address: 9225 Clendenen, Sacramento, CA 95823
b. Date of birth: 09/05/2006 c. Age: 17 d. Minor or (}Person with a disability
(If the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a
conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.))
e. [Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order.
f. [Does not have a conservator of the estate.
Qualification for Expedited Approval
a. The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another.
b. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust.
c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.
d Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the
claim is asserted or a party's insurance carrier.
Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.
All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court
has made a final determination that all settling parties entered into the settlement in good faith.
(1) The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and
12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or
(2) [2] the settlement described in item 11 represents payment of the single-person policy limits of all liability insurance
policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of
those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in
Attachment 3.)
Page 1 of 7
Form Adopted forAliC Hemnative Mandatory Use PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF ‘ade of Civil Procedure, § 372.
Instead of For Probate Code, §§ 3500, 3600-3613;
Judicial
-350EXCouncil
[Rev. ofJanuary
California1, 201] CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF 1 yes of Court ful ies 3
50.5, 7.951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www courts. c2.gov
CEB Essential
ceb.com {2\Forms-
MC-350EX
CASE NAME: CASE NUMBER:
IN RE: RIBLETT, ASHLYNN
4 Claim The claim of the minor or adult person with a disability:
Is not the subject of a pending action or proceeding. (Complete items 5-23.)
b. [C] Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.)
Name of court
Case no. Trial date
c. [CC] Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the
defendants named below in the amount (exclusive of interest and costs) of (specify). $
efendants (names)
(CdAdditional defendants listed on Attachment 4. CoTThe judgment was filed on (date)
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.)
5. Incident or accident The incident or accident occurred as follows:
a. Date 04-13-2022 Time: 8:40 p.m
b. Place: Riverside Blvd.,near Greenhaven Drive in Sacramento, California
Persons involved (names).
Xzavier Knott, Casey Robinson and Ashlynn Riblett
(C) Additional persons listed on Attachment 5.
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe what happened)
Mr Knott was driving westbound on Riverside Boulevard at approximately 60 mph when he
made an abrupt left turn continuing westbound into the eastbound lanes of Riverside
Boulevard Knott made contact with the south curbline then losing control colliding
into a tree Vehicle overturned
Progressive tendered the per person policy limit of $15,000 to Ms Riblett
(CX) Continued on Attachment 6.
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Collapsed lungs, multiple facial fractures, bruised kidney and a fractured hip
(2) Continued on Attachment 7.
Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe).
Kaiser Permanente Hospital
(X] Continued on Attachment 8.
MC-S508 Rev. January 1,202 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 2 of 7
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
Forms: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: CASE NUMBER:
IN RE: RIBLETT, ASHLYNN
Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries
or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as
Attachment 9. A new report is not necessary if a previous report accurately describes the claimant's current condition.)
a. The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent
injuries.
b. [2] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms):
() Continued on Attachment 9b.
c. [2] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms):
() Continued on Attachment 9c.
10. [X] Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident
or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is
approved by the court and consummated, the claimant will never be able to recover any more compensation from the
settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear.
11 Amount and terms of settlement
To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant:
a. The total amount offered by all defendants named below is (specify): $ 15,000.00
b. The defendants and amounts offered by each are as follows (specify):
Defendants (names) Amounts
Progressive Insurance on behalf of Rodney Stevens $ 15,000.00
$
$
$
(C) Additional defendants and amounts offered are listed on Attachment 1 1b.
c. The terms of settlement are described on Attachment 11c. (if the settlement is to be paid in installments, both the total amount
and the present value of the settlement must be included.)
12. Settlement payments to others
a. [No defendant named in item 11b has offered to pay money to any person or persons other than the claimant to settle
aims arising out of the same incident or accident that resulted in the claimant's injury.
e or more of the defendants named in item 11b have also offered to pay money to a person or persons other than
claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury.
(1) The total amount offered by all defendants to others (specify): $ 15,000
(2) (}Petitioner would receive money under the proposed settlement.
(3) The settlement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
Casey Robinson $ 15,000.00
$
$
$
(Additional plaintiffs or claimants and amounts are listed on Attachment 12.
(4) [JThe settlement payments are apportioned between the claimant and each other plaintiff or claimant named above on
a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other
plaintiff or claimant are specified on Attachment 12.
(5) QaReasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant
named above are specified on Attachment 12.
MC-350EX (Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 3 of 7
CB
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Essential
{2\Forms"
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: CASE NUMBER:
IN RE: RIBLETT, ASHLYNN
13. Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to
be paid or reimbursed from the proceeds of the settlement or judgment
a Totals
(1) Total medical expenses before any reductions: 311,005.41
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ 177,160.00
(3) Total of negotiated, contractual, or statutory reductions, if any: ($ 169,660.00
(4) Total amount of medical expenses to be paid or reimbursed from proceeds: 7,500.00
(5) Total amount of statutory or contractual liens, if any: 7,500.00
(Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5)
in Attachment 13a.)
(1) BQNone of the claimant's medical expenses have been paid by Medicare
(2) [JMedicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights,
Medicare will be reimbursed in the amount of:
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(2).)
(1) EXQNone of the claimant's medical expenses have been paid by Medi-Cal
(2) (JMedi-Cal paid some or all of claimant's medical expenses.
(a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.)
A copy of the notice and proof of delivery [J]Jis attached [Jwas filed in this matter on (date):
(b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $
(Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 13c(2).)
(he claimant's health plan is requesting reimbursement for medical expenses paid under the plan.
In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ 7,500.00
(Attach statements from the plan showing expense payments and requesting reimbursement.)
(}Petitioner has paid claimant's medical expenses to be reimbursed in the amount of: $
(See instructions for item 15.)
(1) [cyTthere are no statutory or contractual liens for payment of the claimant's medical expenses.
(2) Qqthere are one or more liens from medical service providers for payment of the claimant's medical expenses.
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ 7,500.00
(Select (1) or (2) below.)
(1) atest statements from all medical service providers are attached as Attachment 13g.
(2) LAI medical expenses have been paid by private insurance, Medicare, or Medi-Cal.
14. Claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner
and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment
a. Total amount of attorney's fees for which court approval is requested: $o
(If fees are requested, attach as Attachment 14a a declaration from the attorney explaining the basis for the request, including a
discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attorney fee
agreement in Attachment 14a.)
The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or
judgment:
Items Payees (names) Amounts
[Continued on Attachment 14b. Total: $_0
c. [J Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based
on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 14c.
Gs
MC-350EX (Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 4 of 7
Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
j2\Forms- JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: CASE NUMBER:
IN RE: RIBLETT, ASHLYNN
15. Reimbursement of fees and expenses paid by petitioner
Petitioner has paid none of the fees or expenses listed in items 13 and 14 for which reimbursement is requested.
b. a Petitioner has paid the following total amounts of the claimant's fees and expenses for which reimbursement is requested.
) CoMedical expenses listed in item 13: $
(AAttorney's fees included in the total fee amount shown in item 14a: $
()p ther expenses included in the total shown in item 14b: $
(Attach proofs of the fees and expenses incurred and payments made, e.g., bills or invoices, Total $
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
16. Net balance of proceeds remaining for claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
after payment or reimbursement of all requested fees and expenses is (specify). 7,500.00
17. Summary
Gross amount of proceeds of settlement or judgment for claimant: $ 15,000.00
Medical expenses to be paid from proceeds of settlement or judgment: $ 7,500.00
Attorney's fees to be paid from proceeds of settlement or judgment $ 0.00
Expenses (other than medical) to be paid from proceeds of settlement $ 0.00
or judgment:
Total fees and expenses to be paid from proceeds of settlement or
judgment (add (b), (c), and (d)) ($ 7,500.00 )
Balance of proceeds of settlement or judgment available for claimant
after payment of all fees and expenses (subtract (e) from (a)). $ 7,500.00
18. Information about attorney representing or assisting petitioner
a. Theattorney [Jisnot Gis representing or employed by another party involved in this matter.
(If you answered identify the other party and explain the relationship in Attachment 18a. If the other party is a defendant,
you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1
and Cal. Rules of Court, rule 7.950.5(a)(6).)
The attorney [has neither received nor expects to receive as received or expects to receive attorney's fees or
other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to
this petition (if you answered “has received or expects to receive," identify the person who paid or will pay the fees or other
compensation, the amounts paid or to be paid, and the dates of payment or expected payment).
Amount
From Whom Paid or Expected (name). Date Paid or Expected Paid or Expected
Attorney fees to be paid by Progressive Insurance
Total:
Continued on Attachment 18b.
MC-2508% [Rev January 1, 2021 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 5 of 7
CEB:Fs Forms: CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: [ case nuwBER:
[=v RE: RIBLETT, ASHLYNN
I
|
19. Disposition of balance to claimant (check either a or b, then check each option requested and enter amount(s)):
a. [) There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability
filed in (name of court):
Case no.:
(1) [c} Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the
guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is
specified in Attachment 19a(1).
(2) [) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner
requests authority to deposit or invest $ of the money or other property to be paid or delivered
under 19a(1) in one or more insured accounts with financial institutions in this state or with a trust company, subject to
withdrawal only on authorization of the court. The money or other property and the name, branch, and address of
each financial institution or trust company are specified in Attachment 19a(2).
(3) [}Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship
estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply):
@) CS to be deposited in insured accounts in one or more financial institutions in this state,
subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are
specified in Attachment 19a(3)(a).
(b) CS to be invested in a single-premium deferred annuity, subject to withdrawal only on
authorization of the court. The terms and conditions of the annuity are specified in Attachment 19a(3)(b).
(c) CS to be transferred to a custodian for the 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 in Attachment 19a(3)(c).
There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability.
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
(check all that apply):
(1) CVA guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed
and $ of money and other property be paid or delivered to the person so appointed. The money
or other property are specified in Attachment 19b(1).
(2) $ 7,500.00 of money be deposited in insured accounts in one or more financial institutions in this state,
subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are
specified in Attachment 19b(2).
(3) Cas of money be invested in a single-premium deferred annuity, subject to withdrawal only on
authorization of the court. The terms and conditions of the annuity are specified in Attachment 19b(3).
(4) Cis be paid or delivered to a parent of the minor on 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 in Attachment 19b(4). (Value of minor's entire estate, including the money or
property to be delivered, must not exceed $5,000.)
(6) Cas be transferred to a custodian for the benefit of the minor under the California Uniform Transfers
to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred
are specified in Attachment 19b(5).
(6) $ of money be held on the conditions that the court determines to be in the best interest of the
minor or adult person with a disability. The proposed conditions are specified on Attachment 19b(6). (Value must not
exceed $20,000.)
(7) Cis of property other than money be held on the conditions that the court determines to be in the
best interest of the minor or adult person with a disability. The proposed conditions and the property are specified in
Attachment 19b(7).
(8) $ be deposited with the county treasurer of the County of (name):
The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h).
@) Cas be paid or transferred to the adult person with a disability. The money or other property is
specified in Attachment 19b(9).
Gs
MC-350EX (Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 6 of 7
Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
j2\Forms- JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350EX
CASE NAME: CASE NUMBER:
IN RE: RIBLETT, ASHLYNN
20. GX] Additional orders
Petitioner requests the following additional orders (specify and explain).
Petitioner Carl Riblett to provide a fully executed release and settlement on behalf of
Ashlynn Riblett (a minor )
(2) Continued on Attachment 20.
21. [CQ], the claimant named in item 2, consent to the order or judgment requested in this petition.
(Required if the claimant is an adult with a disability who has the capacity, under Probate Code section 812, to consent to the
order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.))
Date:
(TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT)
22. Petitioner recommends the proposed compromise, settlement, or disposition of judgment proceeds for the claimant to the court as
being fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise.
settlement, or disposition and make any other orders that are just and reasonable.
23 Number of pages attached
Date: March 8, 2024
ELIZABETH S CARLSEN, ESQ » Bgabett Carben
(TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY)
| declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date: Feb 3, 2024
de
CARL RIBLETT De Seite er PT
(TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER)
MC-S508 Rev. January 1,202 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 7 of 7
CEB:Fs Forms: CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-025
SHORT TITLE: CASE NUMBER.
| IN RE: RIBLETT, ASHLYNN
ATTACHMENT (Number): 1
(This Attachment may be used with any Judicial Council form.)
Attachment 1:
DECLARATION OF PETITIONER CARL RIBLETT RE: PROBATE CODE SECTION 3500(a)
(RIGHT TO COMPROMISE MINOR'S CLAIM)
I, Carl Riblett, declare as follows:
1. Iam claimant Ashlynn Riblett, father and parent. I make this declaration based upon my own personal
knowledge.
2. Ashlynn Riblett does not have a guardian of the estate. No appointment of a guardian ad litem has been
made regarding this matter.
3. Ihad care, custody, and control of Ashlynn Riblett on April 13, 2022, the day of the accident in this matter,
which continues to the present.
I declare under the penalty of perjury under the laws of the state of California that the foregoing is true and
correct.
DATED:
Feb 3, 2024
We
arl Feb
3, 2024 13:58 PST)
Carl Riblett
(If the item that this Attachment concems is made under penalty of perjury, all statements in this Page 1 of 1
Attachment are made under penalty of perjury.)
(Add pages as required)
Form Approved for Optional Use ATTACHMENT www courtinfo.ca.gov
Judicial Council of California
MC-025 [Rev. July 1, 2003} to Judicial Council Form
2023.10.05 - EX Petition for Approval of Minor's
Comp (S)
Final Audit Report 2024-02-03
Created: 2024-01-12
By: Mike Quinn (mquinn@bateswinterlaw.com)
Status: Signed
Transaction ID: CBJCHBCAABAAPJ_dUDvpwdczWRG6-GXxJjcjFffwbglE
"2023.10.05 - EX Petition for Approval of Minor's Comp (S)" Hist
ory
©) Document created by Mike Quinn (mquinn@bateswinterlaw.com)
2024-01-12 - 0:41:42 AM GMT- IP address: 66.60.189.59
B Document emailed to carl.riblett@icloud.com for signature
2024-01-12 - 0:42:54 AM GMT
a Email viewed by carl.riblett@icloud.com
2024-01-14 - 2:54:21 AM GMT- IP address: 98.255.50.122
B New document URL requested by carl.riblett@icloud.com
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Email viewed by carl.riblett@icloud.com
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% Signer carl.riblett@icloud.com entered name at signing as Carl
2024-02-03 - 9:58:35 PM GMT- IP address: 104,28,124,167
% Document e-signed by Carl (carl.riblett@icloud.com)
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Agreement completed.
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Adobe Acrobat Sign
MC-025
SHORT TITLE: CASE NUMBER:
| IN RE: RIBLETT, ASHLYNN
ATTACHMENT (Number): 6
(This Attachment may be used with any Judicial Council form.)
Please find attached hereto a copy of the Traffic Collision Report.
(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of
Attachment are made under penalty of perjury.)
(Add pages as required)
Form Approved for Optional Use ATTACHMENT www. courtinfo.ca.gov
Judicial Council of California
‘MC-025 [Rev. July 1, 2009] to Judicial Council Form
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MC-350EX ATTORNEY OR PARTY WITHOUT ATTORNEY ‘STATE BAR NUMBER: FOR COURT USE ONLY NAME: ELIZABETH S. CARLSEN, SBN 270293 FIRM NAME: BATES WINTER TALMACHOFF VANDERSLUYS LLP ‘STREET ADDRESS: 925 HIGHLAND POINT DRIVE, STE. 380 city: ROSEVILLE sTaTe: CA ZIPCODE: 95678 ELECTRONICALLY FILED uperior Court of California ‘TELEPHONE NO, 916-789-7080 FAXNO.: 916-789-7090 ounty of Sacramento EMAILADDRESS:ecarlsen@bateswinterlaw.com 03/08/2024 ATTORNEY FOR (Name): Rodne Stevens SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO By: T. Crowther Dey uty ‘STREET ADDRESS: 720 Ninth Street MAILING ADDRESS: SAME CITY AND ZIP CODE: Sacramento, California 95814 BRANCH NAME: Gordon D. Schaber Courthouse CASE NAME: CASE NUMBER: IN RE: ASHLYNN RIBLETT 24cyv0044531 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF [XNo hearing date is requested. CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF Cdearine vate: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY DEPT. TIME: NOTICE TO PETITIONER !You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) compromise lof a pending action or proceeding in which a minor ora person with a disability (including a conservatee) is a party, or (3) disposition of the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) You Imay request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and either 3g(1) or 3g(2), below, are true and accurate; and (3) the court does not otherwise order. If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing. 1 Petitioner (name or pseudonym’). CARL RIBLETT_ (See Attachment 1) is the (check all boxes that apply): (Parent [Guardian ad litem* CQcuardian Clconservator (other (specify relationship): of the claimant identified in item 2. (“Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ. Proc., § 372.5.)) Claimant (name): ASHLYNN RIBLETT, a minor a. Address: 9225 Clendenen, Sacramento, CA 95823 b. Date of birth: 09/05/2006 c. Age: 17 d. Minor or (}Person with a disability (If the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.)) e. [Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order. f. [Does not have a conservator of the estate. Qualification for Expedited Approval a. The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another. b. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust. c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement. d Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court has made a final determination that all settling parties entered into the settlement in good faith. (1) The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and 12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or (2) [2] the settlement described in item 11 represents payment of the single-person policy limits of all liability insurance policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in Attachment 3.) Page 1 of 7 Form Adopted forAliC Hemnative Mandatory Use PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF ‘ade of Civil Procedure, § 372. Instead of For Probate Code, §§ 3500, 3600-3613; Judicial -350EXCouncil [Rev. ofJanuary California1, 201] CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF 1 yes of Court ful ies 3 50.5, 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www courts. c2.gov CEB Essential ceb.com {2\Forms- MC-350EX CASE NAME: CASE NUMBER: IN RE: RIBLETT, ASHLYNN 4 Claim The claim of the minor or adult person with a disability: Is not the subject of a pending action or proceeding. (Complete items 5-23.) b. [C] Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.) Name of court Case no. Trial date c. [CC] Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the defendants named below in the amount (exclusive of interest and costs) of (specify). $ efendants (names) (CdAdditional defendants listed on Attachment 4. CoTThe judgment was filed on (date) (Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.) 5. Incident or accident The incident or accident occurred as follows: a. Date 04-13-2022 Time: 8:40 p.m b. Place: Riverside Blvd.,near Greenhaven Drive in Sacramento, California Persons involved (names). Xzavier Knott, Casey Robinson and Ashlynn Riblett (C) Additional persons listed on Attachment 5. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened) Mr Knott was driving westbound on Riverside Boulevard at approximately 60 mph when he made an abrupt left turn continuing westbound into the eastbound lanes of Riverside Boulevard Knott made contact with the south curbline then losing control colliding into a tree Vehicle overturned Progressive tendered the per person policy limit of $15,000 to Ms Riblett (CX) Continued on Attachment 6. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Collapsed lungs, multiple facial fractures, bruised kidney and a fractured hip (2) Continued on Attachment 7. Treatment The claimant received the following care and treatment for the injuries described in item 7 (describe). Kaiser Permanente Hospital (X] Continued on Attachment 8. MC-S508 Rev. January 1,202 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 2 of 7 CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF Forms: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: CASE NUMBER: IN RE: RIBLETT, ASHLYNN Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 9. A new report is not necessary if a previous report accurately describes the claimant's current condition.) a. The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent injuries. b. [2] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): () Continued on Attachment 9b. c. [2] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms): () Continued on Attachment 9c. 10. [X] Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is approved by the court and consummated, the claimant will never be able to recover any more compensation from the settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear. 11 Amount and terms of settlement To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant: a. The total amount offered by all defendants named below is (specify): $ 15,000.00 b. The defendants and amounts offered by each are as follows (specify): Defendants (names) Amounts Progressive Insurance on behalf of Rodney Stevens $ 15,000.00 $ $ $ (C) Additional defendants and amounts offered are listed on Attachment 1 1b. c. The terms of settlement are described on Attachment 11c. (if the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.) 12. Settlement payments to others a. [No defendant named in item 11b has offered to pay money to any person or persons other than the claimant to settle aims arising out of the same incident or accident that resulted in the claimant's injury. e or more of the defendants named in item 11b have also offered to pay money to a person or persons other than claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. (1) The total amount offered by all defendants to others (specify): $ 15,000 (2) (}Petitioner would receive money under the proposed settlement. (3) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts Casey Robinson $ 15,000.00 $ $ $ (Additional plaintiffs or claimants and amounts are listed on Attachment 12. (4) [JThe settlement payments are apportioned between the claimant and each other plaintiff or claimant named above on a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other plaintiff or claimant are specified on Attachment 12. (5) QaReasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 12. MC-350EX (Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 3 of 7 CB ceb.com Essential {2\Forms" CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: CASE NUMBER: IN RE: RIBLETT, ASHLYNN 13. Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to be paid or reimbursed from the proceeds of the settlement or judgment a Totals (1) Total medical expenses before any reductions: 311,005.41 (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ 177,160.00 (3) Total of negotiated, contractual, or statutory reductions, if any: ($ 169,660.00 (4) Total amount of medical expenses to be paid or reimbursed from proceeds: 7,500.00 (5) Total amount of statutory or contractual liens, if any: 7,500.00 (Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5) in Attachment 13a.) (1) BQNone of the claimant's medical expenses have been paid by Medicare (2) [JMedicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights, Medicare will be reimbursed in the amount of: (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(2).) (1) EXQNone of the claimant's medical expenses have been paid by Medi-Cal (2) (JMedi-Cal paid some or all of claimant's medical expenses. (a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.) A copy of the notice and proof of delivery [J]Jis attached [Jwas filed in this matter on (date): (b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 13c(2).) (he claimant's health plan is requesting reimbursement for medical expenses paid under the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ 7,500.00 (Attach statements from the plan showing expense payments and requesting reimbursement.) (}Petitioner has paid claimant's medical expenses to be reimbursed in the amount of: $ (See instructions for item 15.) (1) [cyTthere are no statutory or contractual liens for payment of the claimant's medical expenses. (2) Qqthere are one or more liens from medical service providers for payment of the claimant's medical expenses. In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ 7,500.00 (Select (1) or (2) below.) (1) atest statements from all medical service providers are attached as Attachment 13g. (2) LAI medical expenses have been paid by private insurance, Medicare, or Medi-Cal. 14. Claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment a. Total amount of attorney's fees for which court approval is requested: $o (If fees are requested, attach as Attachment 14a a declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Include a copy of any written attorney fee agreement in Attachment 14a.) The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts [Continued on Attachment 14b. Total: $_0 c. [J Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 14c. Gs MC-350EX (Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 4 of 7 Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF j2\Forms- JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: CASE NUMBER: IN RE: RIBLETT, ASHLYNN 15. Reimbursement of fees and expenses paid by petitioner Petitioner has paid none of the fees or expenses listed in items 13 and 14 for which reimbursement is requested. b. a Petitioner has paid the following total amounts of the claimant's fees and expenses for which reimbursement is requested. ) CoMedical expenses listed in item 13: $ (AAttorney's fees included in the total fee amount shown in item 14a: $ ()p ther expenses included in the total shown in item 14b: $ (Attach proofs of the fees and expenses incurred and payments made, e.g., bills or invoices, Total $ canceled checks, credit card statements, explanations of benefits from insurers, etc.) 16. Net balance of proceeds remaining for claimant The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment or reimbursement of all requested fees and expenses is (specify). 7,500.00 17. Summary Gross amount of proceeds of settlement or judgment for claimant: $ 15,000.00 Medical expenses to be paid from proceeds of settlement or judgment: $ 7,500.00 Attorney's fees to be paid from proceeds of settlement or judgment $ 0.00 Expenses (other than medical) to be paid from proceeds of settlement $ 0.00 or judgment: Total fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)) ($ 7,500.00 ) Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)). $ 7,500.00 18. Information about attorney representing or assisting petitioner a. Theattorney [Jisnot Gis representing or employed by another party involved in this matter. (If you answered identify the other party and explain the relationship in Attachment 18a. If the other party is a defendant, you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1 and Cal. Rules of Court, rule 7.950.5(a)(6).) The attorney [has neither received nor expects to receive as received or expects to receive attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition (if you answered “has received or expects to receive," identify the person who paid or will pay the fees or other compensation, the amounts paid or to be paid, and the dates of payment or expected payment). Amount From Whom Paid or Expected (name). Date Paid or Expected Paid or Expected Attorney fees to be paid by Progressive Insurance Total: Continued on Attachment 18b. MC-2508% [Rev January 1, 2021 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 5 of 7 CEB:Fs Forms: CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: [ case nuwBER: [=v RE: RIBLETT, ASHLYNN I | 19. Disposition of balance to claimant (check either a or b, then check each option requested and enter amount(s)): a. [) There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability filed in (name of court): Case no.: (1) [c} Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is specified in Attachment 19a(1). (2) [) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ of the money or other property to be paid or delivered under 19a(1) in one or more insured accounts with financial institutions in this state or with a trust company, subject to withdrawal only on authorization of the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 19a(2). (3) [}Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply): @) CS to be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 19a(3)(a). (b) CS to be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 19a(3)(b). (c) CS to be transferred to a custodian for the 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 in Attachment 19a(3)(c). There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability. Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check all that apply): (1) CVA guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed and $ of money and other property be paid or delivered to the person so appointed. The money or other property are specified in Attachment 19b(1). (2) $ 7,500.00 of money be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 19b(2). (3) Cas of money be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 19b(3). (4) Cis be paid or delivered to a parent of the minor on 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 in Attachment 19b(4). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) (6) Cas be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 19b(5). (6) $ of money be held on the conditions that the court determines to be in the best interest of the minor or adult person with a disability. The proposed conditions are specified on Attachment 19b(6). (Value must not exceed $20,000.) (7) Cis of property other than money be held on the conditions that the court determines to be in the best interest of the minor or adult person with a disability. The proposed conditions and the property are specified in Attachment 19b(7). (8) $ be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h). @) Cas be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 19b(9). Gs MC-350EX (Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 6 of 7 Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF j2\Forms- JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350EX CASE NAME: CASE NUMBER: IN RE: RIBLETT, ASHLYNN 20. GX] Additional orders Petitioner requests the following additional orders (specify and explain). Petitioner Carl Riblett to provide a fully executed release and settlement on behalf of Ashlynn Riblett (a minor ) (2) Continued on Attachment 20. 21. [CQ], the claimant named in item 2, consent to the order or judgment requested in this petition. (Required if the claimant is an adult with a disability who has the capacity, under Probate Code section 812, to consent to the order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.)) Date: (TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT) 22. Petitioner recommends the proposed compromise, settlement, or disposition of judgment proceeds for the claimant to the court as being fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise. settlement, or disposition and make any other orders that are just and reasonable. 23 Number of pages attached Date: March 8, 2024 ELIZABETH S CARLSEN, ESQ » Bgabett Carben (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY) | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Feb 3, 2024 de CARL RIBLETT De Seite er PT (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) MC-S508 Rev. January 1,202 PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 7 of 7 CEB:Fs Forms: CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-025 SHORT TITLE: CASE NUMBER. | IN RE: RIBLETT, ASHLYNN ATTACHMENT (Number): 1 (This Attachment may be used with any Judicial Council form.) Attachment 1: DECLARATION OF PETITIONER CARL RIBLETT RE: PROBATE CODE SECTION 3500(a) (RIGHT TO COMPROMISE MINOR'S CLAIM) I, Carl Riblett, declare as follows: 1. Iam claimant Ashlynn Riblett, father and parent. I make this declaration based upon my own personal knowledge. 2. Ashlynn Riblett does not have a guardian of the estate. No appointment of a guardian ad litem has been made regarding this matter. 3. Ihad care, custody, and control of Ashlynn Riblett on April 13, 2022, the day of the accident in this matter, which continues to the present. I declare under the penalty of perjury under the laws of the state of California that the foregoing is true and correct. DATED: Feb 3, 2024 We arl Feb 3, 2024 13:58 PST) Carl Riblett (If the item that this Attachment concems is made under penalty of perjury, all statements in this Page 1 of 1 Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use ATTACHMENT www courtinfo.ca.gov Judicial Council of California MC-025 [Rev. July 1, 2003} to Judicial Council Form 2023.10.05 - EX Petition for Approval of Minor's Comp (S) Final Audit Report 2024-02-03 Created: 2024-01-12 By: Mike Quinn (mquinn@bateswinterlaw.com) Status: Signed Transaction ID: CBJCHBCAABAAPJ_dUDvpwdczWRG6-GXxJjcjFffwbglE "2023.10.05 - EX Petition for Approval of Minor's Comp (S)" Hist ory ©) Document created by Mike Quinn (mquinn@bateswinterlaw.com) 2024-01-12 - 0:41:42 AM GMT- IP address: 66.60.189.59 B Document emailed to carl.riblett@icloud.com for signature 2024-01-12 - 0:42:54 AM GMT a Email viewed by carl.riblett@icloud.com 2024-01-14 - 2:54:21 AM GMT- IP address: 98.255.50.122 B New document URL requested by carl.riblett@icloud.com 2024-02-03 - 9:57:53 PM GMT- IP address: 104.28,.124.167 Email viewed by carl.riblett@icloud.com 2024-02-03 - 9:58:05 PM GMT- IP address: 104.28.124.167 % Signer carl.riblett@icloud.com entered name at signing as Carl 2024-02-03 - 9:58:35 PM GMT- IP address: 104,28,124,167 % Document e-signed by Carl (carl.riblett@icloud.com) Signature Date: 2024-02-03 - 9:58:37 PM GMT - Time Source: server- IP address: 104.28.124.167 Agreement completed. 2024-02-03 - 9:58:37 PM GMT Adobe Acrobat Sign MC-025 SHORT TITLE: CASE NUMBER: | IN RE: RIBLETT, ASHLYNN ATTACHMENT (Number): 6 (This Attachment may be used with any Judicial Council form.) Please find attached hereto a copy of the Traffic Collision Report. (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use ATTACHMENT www. courtinfo.ca.gov Judicial Council of California ‘MC-025 [Rev. July 1, 2009] to Judicial Council Form ~ neg te STATE OF CALIFORNIA, DEPARTMENT OF CALIFORNIA HIGHWAY PATROL : wily hy ifty i r“er TRAFFIC COLLISION REPORT { a at CHP 555 Page 1 (Rev. 4-11) OPI060_ ) \.Sea / cALT Tepese MoM. er A PARTY| DRIVERS LICENSE NUMBER STATE cass FIR BAG SAFETY EGU VER YEAR WAKEMODELCOLOR TICENGE NeREBER EREi 3 8o DRIVER | NAME [FIRST MIDDLE LAST) *3 O OWNERS NAME [Jsawe as onver PEgES-| STREET ADORESS OWNERS ADDRESS [same as oniver [paRco} omrvisraTerZP U i; . SPST REET Jomcee Comes st a HAIR ES HEIGHT WEIGHT BIRTHOATE RACE [PRIOR MECHANICAL DEFECTS: [IJNONE APPARENT BO] REFER TO NARRATIVE ‘OTHER | HOME PHONE. ‘BUSINESS PHONE | VEHICLE IDENTIFICATION NUMBER VENIGLE TPE (DESCRIBE VEHICLE DAMAGE ‘SHADE IN DAMAGED AREA [hunk [none minor 3 a INSURANCE CARRIER POLICY NUMBER | Clos Fuaion [Jrouover RE (ON STREET OR HIGHWAY ‘SPEED UMATT ca vor Nn >) cat TepPse MoiMK. (PREPARER'S NAME DISPATCH NOTIFIED, DATE REVIEWED serene Robert Hamm #3018 OFC. DETHLEFS #649 Eves [no Ona eer ET ‘An Internationally Accredited Agency (Chp555_0411 pat STATE OF CALIFORNIA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL TRAFFIC COLLISION CODING CHP 555 Page 2 (Rev. 4-11) OPI 060 == page 2 2X1 [DATE OF COLLISION (MO, DAY YEAR) TiME (2400) Nei ® OFFICER. NUMBER 04/13/2022 2043 3404 649 22-104652 ‘OWNERS NAME. OWNERS ADDRESS NOTIFIED PROPERTY |XFINITY 1701 JOHN F KENNEDY BLVD PHILADELPHIA, PA |XJves_ [xo DAMAGE (DESCRIPTION OF DAMAGE BROKEN CABLE AND INTERNET BOX. SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES B- UNKNOWN ‘A CELLPHONE HANDHELD AN A-NONEIN VEHICLE Q- IN VEHICLE USED L-AIR BAG DEPLOYED B - CELLPHONE HANDSFREE 8 -UNI R- IN VEHICLE NOT USED M-AIR BAG NOT DEPLOYED. C- ELECTRONIC EQUIPMENT LAP BELT USED S -IN VEHICLE USE UNKNOWN N-OTHER, D-RADIO/ CD. D- LAP BELT NOT USED TIN VEHICLE IMPROPER USE P -NOT REQUIRED E - SMOKING 1-DRIVER E - SHOULDER HARNESS USED. U- NONE IN VEHICLE F EATING 123 270 6 - PASSENGERS F - SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE G-CHILOREN 7 - STATION WAGON REAR ‘G - LAPISHOULDER HARNESS USED 0 - NOT EJECTED H- ANIMAL 8- REAR OCC. TRK. OR VAN H - LAPISHOULDER HARNESS NOT USEO. Saves 456 PASSENGER: 1 - FULLY EJECTED | PERSONAL HYGIENE 9 POSITION UNKNOWN J -PASSIVE RESTRAINT USED. =NO : iO 2 - PARTIALLY EJECTED. J REAL iG 0- OTHER K - PASSIVE RESTRAINT NOT USED W-YES Y-YES 3 - UNKNOWN K- OTHER P -NOT REQUIRED ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR: LIST NUMBER (#)OF PARTY AT FAULT VE SECTION VOLATED ai +2, ‘A TRAFFIC CONTROL DEVICES CONTROLS FUNCTIONING 1 2\3 ‘SPECIAL INFORMATION ‘A_HAZARDOUS MATERIAL 1/2/3 a