Dauphin Cnty. C.P. Rule 2039A - Form

RULE 2039A FORM

___________, Parent and Natural Guardian: In the Court of Common Pleas

of ___________, a minor, : Dauphin County, Pennsylvania

Plaintiff:

:

v. : No.

:

_________________, :

Defendant:

ORDER

AND NOW THIS _______ day of ________, 20____, upon consideration of the

Petition for Approval of Minor’s Settlement, it is hereby ordered that the Petitioner is

authorized to enter into a settlement in the gross sum of __________. Petitioner is

authorized to sign a release and to mark the matter settled, discontinued and ended as

to the above defendant(s).

The settlement amount shall be distributed as follows:

TO: _____________, attorney at law, $_____ for counsel fees;

TO: _____________, attorney at law, $_____ for reimbursement of costs;

TO: _____________, as Parent and Natural Guardian of _________, a minor,

$________ to be deposited into a restricted, federally insured account marked “No

withdrawals prior to age 18 without prior court approval.”

TOTAL AMOUNT OF DISTRIBUTION: $________

Counsel shall provide to the Court, within ten (10) days from the date of this order proof

of such deposit.

BY THE COURT:

__________________________

J.