Preview
_MC-351
FOR COURT USE ONLY
Wmflmmsmwm,wmx
KELSEY D.DePAOLI, ESQ. SBN # 283310
LAW OFFICE OF BLACK & DePAO LI, APC
1839 IRON POINT ROAD, SUITE 160
FOLSOM CA 95630
962-2896 FAXNO. (Optiona): (916__ 983-63
~ TeLePHONENO: (916)
E-MAIL ADDRESS (Optina): Gina@bdlawteam.com
ATTORNEY FOR (Name): Petitioner
SUPERIOR COURT OF CALIFORNIA, COUNTYOF SACRAMENTO
sTReeTADDRess: 720 - 9TH STREET
MAILING ADDRESs: 720 - 9TH STREET
oy ANpzipcope: SACRAMENTO, CA 95814
BRANCH NAME:
GUARDIAN AD LITEM FOR AMIA
CASE NAME: SHEMLIA CARTER,
ADKINS
ISPUTEDUTED CLAI CLAIM
'geeOF& DISP
X Ec%um:vlMISE mu\ N 10095933
GOMPROMI SE OF PENDI NG ACTION 24C
DISPOSITION OF PROCEEDS OF JUDGMENT ORTE, FGAN, [ OEPT:
RERRIN
[X] Minor [ _] Person With a Disability
ad Litem for AMIA ADKINS has petitioned for court approval ofa
1. Petitioner (name): SHAMELIA CARTER, Guardian a disability or a
or a pending action involving a minor or a person with
proposed compromise of a disputed claim of a minor
a minor or a person with a disability.
proposed disposition of the proceeds of a judgment for
2. Hearing Court.
petition under rule 7.950.5 of the California Rules of
a. [X] No hearing was held. The petition is an expedited
b. [_] Date: Time: Dept.:
¢. Judicial officer:
3. Relationship to claimant
to claimant (check all applicable boxes):
Petitioner has the following relationship or relationships
Parent
Guardian ad litem
D000
Guardian
Conservator
Claimant, an adult person with a disability, is the petitioner.
Other (specify):
4. Claimant (name): AMIA ADKINS
a. [X] isaminor.
section 3603 who is:
b. [ isa "person with a disability" within the meaning of Probate Code
(1) [ An adult. Claimant's date of birth is (specify):
to consent to this order, within the meaning of
(a) [] without a conservator. Claimant has capacity
Probate Code section 812, and has consen ted to this order.
appointed; or without capacity to
(b) C_] A conservatee; a person for whom a conservator may be section 812.
order, within the meanin g of Probat e Code
consent to this
(2) (] A minor described in Probate Code section 3603(b)3).
5. Defendant settling or judgment defendant or
d, or the judgment is entered, against (name of
The claim or action to be compromised is asserte
defendants (the "payer”)): ASHLEY HARVEY
Page 10f4
Om W :‘3.7::'
SE OF DISPUTED CLAIM OR PENDING
@opwsdgr Mandatorylss ORDER APPROVING COMPROMI JUDG MENT FOR cal. of
Rule s
Coutt, rules 3.1384, 7.953
jandagy 1, 2010) ACTION OR DISPOSITION OF PROCEEDS OF
MINOR OR PERSON WITH A DISAB ILITY
‘
(Miscellaneous)
MC-351
CASE NAME: SHEMLIA CARTER, GUARDIAN AD LIETM FOR AMIA
ADKINS -
6. THE COURT FINDS that all notices required by law-have been given.
7. THE COURT ORDERS
or action or the proposed disposition of the proceeds of the
a The petition is granted and the proposed compromise of claim 5,000.00 J
claimant is $ r
of or
in fav
judgment is approved. The gross amount or value of the settlement or judgment
claim for a reduction of a Medi-Cal lien under
Urzlhfurtber order of the court, jurisdiction is reserved to determine a payable
> [ to the Department of Health Care Services
Welfare and Institutions Code section 14124.76. The amount shown further
claimed by the department but is subject to reduction on
in item 7c(1)(d) of this order is the full amount of thefor lien
reduction.
order of the couft upon dete rmination of the claim
jhent approved by this order in the following manner:
¥
¢ The payer shall disburse the prooeeds of the settiement orqu;dg
t
and expe nses a4, :
(1) of feesen
Paym to thebl order eof the petitioner and the
recheeksozdrafls, drawn paya
Fees and expenses shailbepaidbyoneormo ed in this order for the following
to receive paymen t identifi
petitioner's attorney, if any, or directly to third parties entitled settlement or judgment:
be paid out of the proceeds of the
items of expense or damage, which are hereby authorized to
1,152.00 payable to (specify): KELSEY D.
(a) [X] Attomey's fees in the total amount of: $ |
DePAOLI, ESQ.
by the petitioner or the
(b) [X] Reimbursement for medical and all other expenses paid $ |322.20 I
p_efitioner'sattomeyinmetotalamountof:
ble directly to
(c Aedical, hospital, ambulance, nursing, and other like expenses i $ |69.80 -}
; providers as follows, in the total amountof:
Payee (name): DEPT. OF HEALTH CARE SERVICES
(i)
(A) Address: P.O. BOX 997425
SACRAMENTO CA 95899-7425
(B) Amount: $
(ii) Payee (name):
(A) Address:
(B) Amount: $
additional payees in the above format.)
] Continued on Attachment 7c(1)(c). (Provide information about
(d) [ Other authorized disbursements payable directly to third parties in the total amount of:
the name and address of each payee):
(Describe and state the amount of each item and provide
[_] Continued on Attachment 7¢(1)(d). $ l?, 544.00 J :
ment or judgment:
(e) [X]] Total allowance for fees and expenses from the settle
R T R VDB oo, =
UTED CLAIM OR PENDING Page2of4
ORDE R APPR OVIN G COMP ROMI SE OF DISP
MC-351 [Rev. January 1,200 MENT FOR
ACTION OR DISPOSITION OF PROCEEDS OF JUDG
MINOR OR PERSON WITH A DISAB ILITY
(Miscellaneous)
AD LIETM FOR AMIA CASE NUMBER:
| CASE NAME: SHEMLIA CARTER, GUARDIAN
ADKINS
7. THE COURT ORDERS (cont.) ng manner:
ment or judgment approved by this order in the followi
c. The payer shall disburse the proceeds of the settle
(2) Balance :
of all allowed
The balance of the settlement orjudgment available for claimant after payment 3,456.0L|
sr
fees and expenses is: :
The balance shall be disbursed as follows: 3,456.00
$
(@ X1 Byoneormorechecksordmflsinthetotalamountof(specify): Each such check or draft must bear an
to the order of the petitioner as trustee for the claimant.
drawn payable federally insured
is for deposit in one or more interest-bearing,
endorsement on the face or reverse that it and no withdrawals may be made from the
the petitioner as trustee for the claimant,
accounts in the name of is
Money Into Blocked Account (form MC-355), which
accounts except as provided in the Order to Deposit
: sighed ‘contemporaneously with this order ("blocked account”).
the amount to be disbursed ):
(b) [ By the following method(s) (describe each method, including
[ Continued on Attachment 7c(2)(b).
ory liens in favor
under Probate Code section 3604, all statut
(c) ] tfmoneyistobepaidtoa special needs trust of Menta l Health , the state
ces, the state Department
of the state Department of Health Care Servi y in Califo rnia must first be satisf ied by the
any city and count
Department of Developmental Services, and
following method (specify):
[_] Continued on Attachment 7c(2)(c)-
nts
8. [ ] Further orders of the court concemning blocked accou ed to be deposited in a blocked
s concerning any part of the balance order
The court makes the following additional order
account under item 7¢(2)(a): and the petitioner's attoney, if
or draft described in item 7c(2)(a), the petitioner
Within 48 hours of receipt of a check
a. or more blocked accounts
ioner's name as trustee for the claimant in one
any, must deposit the check or draft in the petit
depository, and the amount of each account):
at (specify name, branch, and address of each
[ C@ntinued t_m_Attachment 8a.
Pom NS
555 Feov Janaary1. 207] ORDER APPROVING COMPROM ISE OF DISPUTED CLAIM OR PENDING
OF JUDGMENT FOR
"~ ACTION OR DISPOSITION (o] PRQCEEDS '
MINOR OR PERS ON WITH A DISA BILITY
(Miscellaneous)
AD LIETM FOR AMIA CASE NUMBER:
CASE NAME: SHEMLIA CARTER, GUARDIAN
ADKINS
8. Further orders of the court concerning blocked accountsany part of the balance ordered to be deposited in a blocked
" The court makes the following additional orders concermning
account under itet 7¢(2)(a): of
deliver to each depository at the time of deposit three copies
b. The petitioner and the petitioner’s attomey, if any, must poraneously with this order,
(form MC-355), which is signed contem
the Order to Deposit Money Into Blocked Account Blocked Account (form
and three copies of the Receipt and Acknowledgment of Order for the Deposit of Money Into the
file a copy of the receipt with this court within 15 days of
MC-356). The petitioner or the petitioner's attomey must if any, are to place the balanc e in a
the petitioner's attorney,
deposit. The sole responsibilities of the petitioner and
file a copy of the receipt.
blocked account or accounts and to timely
under item
judgment deposited in a blocked account or accounts
c. The balance of the proceeds of the settiement or
follows (check (1) or (2)): :
7c(2)(a) may be withdrawn onasly from the blocke d account or accounts without a further
No withdrawals of principal or interest may be made
(1) ] court. The
a judge, and bearing the seal of this
written order under this case name and number, signed by
money on deposit is not subject to escheat.
2) [X] The blocked accountor accounts belong to bea minor. The minor was borr’on (date): 9/27/2008
a further
made from the blocked account or accounts without
No withdrawals of prificipal o interest may
by a judicial officer, and bearin g the seal of this
written order under this case name and number, signed the age of 18 years, the deposi tory,
the minor attains
court, until the minor attains the age of 18 years. When by check or draft directl y to the former
directed to pay
without further order of this court, is authorized and money on deposit
ing interest deposited under this order. The
minor, upon proper demand, all moneys includ
is not subject to escheat.
9. [] Authorization to execute settlement documents
The petitioner is authorized to e e settiement documents as follows (check only one):
the
sum approved by this order and the deposit of funds,
a. [ Upon receipt of the full amount of the settiement a full, comple te, and final releas e and
deliver to the payer
petitioner is authorized and directed to execute and of the accide nt or inciden t descri bed in
the claimant by reason
discharge of any and all claims and demands of sal with prejudi ce.
and a properly executed dismis
the petition and the resultant injuries to the claimant to carry out
e any and all documents reasonably necessary
b. [X] The petitioneris authorized and directed to execut
the terms of the settlement.
c. [] The petitioneris authorized and directed (specify):
.
: [ ] Continued on Attachment 9c.
[ not required.
10. Bondis [ ] ordered and fixed in the amount of: $
payer forthwith.
11. A copy of this order shall be served on the
12. [ ] Additional orders
(specify):
The court makes the following additional orders
] Continued on Attachment 12.
Date: JUDICIAL OFFICER
SIGNATURE FOLLOWS LAST ATTACHMENT
[
Paged of 4
UTED CLAIM OR PENDING
G351 [Rev. January 1.2010) ORDER APPROVING COMPROMISE OF DISP
OF JUDGMENT FOR
ACTION OR DISPOSITION OF PROCEEDS
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
Preview
_MC-351 FOR COURT USE ONLY Wmflmmsmwm,wmx KELSEY D.DePAOLI, ESQ. SBN # 283310 LAW OFFICE OF BLACK & DePAO LI, APC 1839 IRON POINT ROAD, SUITE 160 FOLSOM CA 95630 962-2896 FAXNO. (Optiona): (916__ 983-63 ~ TeLePHONENO: (916) E-MAIL ADDRESS (Optina): Gina@bdlawteam.com ATTORNEY FOR (Name): Petitioner SUPERIOR COURT OF CALIFORNIA, COUNTYOF SACRAMENTO sTReeTADDRess: 720 - 9TH STREET MAILING ADDRESs: 720 - 9TH STREET oy ANpzipcope: SACRAMENTO, CA 95814 BRANCH NAME: GUARDIAN AD LITEM FOR AMIA CASE NAME: SHEMLIA CARTER, ADKINS ISPUTEDUTED CLAI CLAIM 'geeOF& DISP X Ec%um:vlMISE mu\ N 10095933 GOMPROMI SE OF PENDI NG ACTION 24C DISPOSITION OF PROCEEDS OF JUDGMENT ORTE, FGAN, [ OEPT: RERRIN [X] Minor [ _] Person With a Disability ad Litem for AMIA ADKINS has petitioned for court approval ofa 1. Petitioner (name): SHAMELIA CARTER, Guardian a disability or a or a pending action involving a minor or a person with proposed compromise of a disputed claim of a minor a minor or a person with a disability. proposed disposition of the proceeds of a judgment for 2. Hearing Court. petition under rule 7.950.5 of the California Rules of a. [X] No hearing was held. The petition is an expedited b. [_] Date: Time: Dept.: ¢. Judicial officer: 3. Relationship to claimant to claimant (check all applicable boxes): Petitioner has the following relationship or relationships Parent Guardian ad litem D000 Guardian Conservator Claimant, an adult person with a disability, is the petitioner. Other (specify): 4. Claimant (name): AMIA ADKINS a. [X] isaminor. section 3603 who is: b. [ isa "person with a disability" within the meaning of Probate Code (1) [ An adult. Claimant's date of birth is (specify): to consent to this order, within the meaning of (a) [] without a conservator. Claimant has capacity Probate Code section 812, and has consen ted to this order. appointed; or without capacity to (b) C_] A conservatee; a person for whom a conservator may be section 812. order, within the meanin g of Probat e Code consent to this (2) (] A minor described in Probate Code section 3603(b)3). 5. Defendant settling or judgment defendant or d, or the judgment is entered, against (name of The claim or action to be compromised is asserte defendants (the "payer”)): ASHLEY HARVEY Page 10f4 Om W :‘3.7::' SE OF DISPUTED CLAIM OR PENDING @opwsdgr Mandatorylss ORDER APPROVING COMPROMI JUDG MENT FOR cal. of Rule s Coutt, rules 3.1384, 7.953 jandagy 1, 2010) ACTION OR DISPOSITION OF PROCEEDS OF MINOR OR PERSON WITH A DISAB ILITY ‘ (Miscellaneous) MC-351 CASE NAME: SHEMLIA CARTER, GUARDIAN AD LIETM FOR AMIA ADKINS - 6. THE COURT FINDS that all notices required by law-have been given. 7. THE COURT ORDERS or action or the proposed disposition of the proceeds of the a The petition is granted and the proposed compromise of claim 5,000.00 J claimant is $ r of or in fav judgment is approved. The gross amount or value of the settlement or judgment claim for a reduction of a Medi-Cal lien under Urzlhfurtber order of the court, jurisdiction is reserved to determine a payable > [ to the Department of Health Care Services Welfare and Institutions Code section 14124.76. The amount shown further claimed by the department but is subject to reduction on in item 7c(1)(d) of this order is the full amount of thefor lien reduction. order of the couft upon dete rmination of the claim jhent approved by this order in the following manner: ¥ ¢ The payer shall disburse the prooeeds of the settiement orqu;dg t and expe nses a4, : (1) of feesen Paym to thebl order eof the petitioner and the recheeksozdrafls, drawn paya Fees and expenses shailbepaidbyoneormo ed in this order for the following to receive paymen t identifi petitioner's attorney, if any, or directly to third parties entitled settlement or judgment: be paid out of the proceeds of the items of expense or damage, which are hereby authorized to 1,152.00 payable to (specify): KELSEY D. (a) [X] Attomey's fees in the total amount of: $ | DePAOLI, ESQ. by the petitioner or the (b) [X] Reimbursement for medical and all other expenses paid $ |322.20 I p_efitioner'sattomeyinmetotalamountof: ble directly to (c Aedical, hospital, ambulance, nursing, and other like expenses i $ |69.80 -} ; providers as follows, in the total amountof: Payee (name): DEPT. OF HEALTH CARE SERVICES (i) (A) Address: P.O. BOX 997425 SACRAMENTO CA 95899-7425 (B) Amount: $ (ii) Payee (name): (A) Address: (B) Amount: $ additional payees in the above format.) ] Continued on Attachment 7c(1)(c). (Provide information about (d) [ Other authorized disbursements payable directly to third parties in the total amount of: the name and address of each payee): (Describe and state the amount of each item and provide [_] Continued on Attachment 7¢(1)(d). $ l?, 544.00 J : ment or judgment: (e) [X]] Total allowance for fees and expenses from the settle R T R VDB oo, = UTED CLAIM OR PENDING Page2of4 ORDE R APPR OVIN G COMP ROMI SE OF DISP MC-351 [Rev. January 1,200 MENT FOR ACTION OR DISPOSITION OF PROCEEDS OF JUDG MINOR OR PERSON WITH A DISAB ILITY (Miscellaneous) AD LIETM FOR AMIA CASE NUMBER: | CASE NAME: SHEMLIA CARTER, GUARDIAN ADKINS 7. THE COURT ORDERS (cont.) ng manner: ment or judgment approved by this order in the followi c. The payer shall disburse the proceeds of the settle (2) Balance : of all allowed The balance of the settlement orjudgment available for claimant after payment 3,456.0L| sr fees and expenses is: : The balance shall be disbursed as follows: 3,456.00 $ (@ X1 Byoneormorechecksordmflsinthetotalamountof(specify): Each such check or draft must bear an to the order of the petitioner as trustee for the claimant. drawn payable federally insured is for deposit in one or more interest-bearing, endorsement on the face or reverse that it and no withdrawals may be made from the the petitioner as trustee for the claimant, accounts in the name of is Money Into Blocked Account (form MC-355), which accounts except as provided in the Order to Deposit : sighed ‘contemporaneously with this order ("blocked account”). the amount to be disbursed ): (b) [ By the following method(s) (describe each method, including [ Continued on Attachment 7c(2)(b). ory liens in favor under Probate Code section 3604, all statut (c) ] tfmoneyistobepaidtoa special needs trust of Menta l Health , the state ces, the state Department of the state Department of Health Care Servi y in Califo rnia must first be satisf ied by the any city and count Department of Developmental Services, and following method (specify): [_] Continued on Attachment 7c(2)(c)- nts 8. [ ] Further orders of the court concemning blocked accou ed to be deposited in a blocked s concerning any part of the balance order The court makes the following additional order account under item 7¢(2)(a): and the petitioner's attoney, if or draft described in item 7c(2)(a), the petitioner Within 48 hours of receipt of a check a. or more blocked accounts ioner's name as trustee for the claimant in one any, must deposit the check or draft in the petit depository, and the amount of each account): at (specify name, branch, and address of each [ C@ntinued t_m_Attachment 8a. Pom NS 555 Feov Janaary1. 207] ORDER APPROVING COMPROM ISE OF DISPUTED CLAIM OR PENDING OF JUDGMENT FOR "~ ACTION OR DISPOSITION (o] PRQCEEDS ' MINOR OR PERS ON WITH A DISA BILITY (Miscellaneous) AD LIETM FOR AMIA CASE NUMBER: CASE NAME: SHEMLIA CARTER, GUARDIAN ADKINS 8. Further orders of the court concerning blocked accountsany part of the balance ordered to be deposited in a blocked " The court makes the following additional orders concermning account under itet 7¢(2)(a): of deliver to each depository at the time of deposit three copies b. The petitioner and the petitioner’s attomey, if any, must poraneously with this order, (form MC-355), which is signed contem the Order to Deposit Money Into Blocked Account Blocked Account (form and three copies of the Receipt and Acknowledgment of Order for the Deposit of Money Into the file a copy of the receipt with this court within 15 days of MC-356). The petitioner or the petitioner's attomey must if any, are to place the balanc e in a the petitioner's attorney, deposit. The sole responsibilities of the petitioner and file a copy of the receipt. blocked account or accounts and to timely under item judgment deposited in a blocked account or accounts c. The balance of the proceeds of the settiement or follows (check (1) or (2)): : 7c(2)(a) may be withdrawn onasly from the blocke d account or accounts without a further No withdrawals of principal or interest may be made (1) ] court. The a judge, and bearing the seal of this written order under this case name and number, signed by money on deposit is not subject to escheat. 2) [X] The blocked accountor accounts belong to bea minor. The minor was borr’on (date): 9/27/2008 a further made from the blocked account or accounts without No withdrawals of prificipal o interest may by a judicial officer, and bearin g the seal of this written order under this case name and number, signed the age of 18 years, the deposi tory, the minor attains court, until the minor attains the age of 18 years. When by check or draft directl y to the former directed to pay without further order of this court, is authorized and money on deposit ing interest deposited under this order. The minor, upon proper demand, all moneys includ is not subject to escheat. 9. [] Authorization to execute settlement documents The petitioner is authorized to e e settiement documents as follows (check only one): the sum approved by this order and the deposit of funds, a. [ Upon receipt of the full amount of the settiement a full, comple te, and final releas e and deliver to the payer petitioner is authorized and directed to execute and of the accide nt or inciden t descri bed in the claimant by reason discharge of any and all claims and demands of sal with prejudi ce. and a properly executed dismis the petition and the resultant injuries to the claimant to carry out e any and all documents reasonably necessary b. [X] The petitioneris authorized and directed to execut the terms of the settlement. c. [] The petitioneris authorized and directed (specify): . : [ ] Continued on Attachment 9c. [ not required. 10. Bondis [ ] ordered and fixed in the amount of: $ payer forthwith. 11. A copy of this order shall be served on the 12. [ ] Additional orders (specify): The court makes the following additional orders ] Continued on Attachment 12. Date: JUDICIAL OFFICER SIGNATURE FOLLOWS LAST ATTACHMENT [ Paged of 4 UTED CLAIM OR PENDING G351 [Rev. January 1.2010) ORDER APPROVING COMPROMISE OF DISP OF JUDGMENT FOR ACTION OR DISPOSITION OF PROCEEDS MINOR OR PERSON WITH A DISABILITY (Miscellaneous)