Form 22.5 - Application To Settle A Claim Of An Adult Ward
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2PROBATE COURT OF TRUMBULL COUNTY, OHIO
JAMES A. FREDERICKA, JUDGE
IN THE MATTER OF _______________________________________________
CASE NO. _____________________
APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD
[R.C. 2111.18, Sup.R. 69]
[Check applicable boxes, complete applicable blanks, strike inapplicable language, and attach supporting documentation.]
The applicant states that: _____________________________________________________________, is an
adult ward residing at ___________________________________________________________________ in this
county who on or about __________________________________, suffered personal injury and/or damage to
property by wrongful act, neglect, or default that entitles this person to maintain an action to recover damages.
Attached is a narrative statement in support of the proffered settlement setting forth a description of the
occurrence, the injury or damage, the treatment progress and current prognosis by the treating physicians, and
other proposed or actual settlements resulting from the same occurrence being paid to the persons other than this
ward. Counsel will advise at the hearing as to liability and collectability.
There is a (full) (partial) settlement offer of $__________________________ without suit being filed.
There is a (full) (partial) settlement offer of $__________________________ after suit was filed; the style
of the case, court, and case number being _________________________________________________.
The proffered settlement should be approved.
Unreimbursed medical and other expenses of $______________________________ have been
incurred. Attached is a list of such expenses and proposed payees.
A reasonable attorney fee for the attorney’s services is $_____________________________ and
reimbursement to the attorney for suit expenses is $__________________________________. A copy
of the attorney’s fee contract that has (has not) received prior approval of this Court, subject to
modification, and an itemization of suit expenses are attached.
This is a structured settlement. All necessary documents, including a statement of the present value of
the settlement, are filed herewith.
FORM 22.5 – APPLICATION TO SETTLE A CLAIM OF AN ADULT WARD
Effective Date: January 1, 2015
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