Dauphin Cnty. C.P. Rule 2206A - Form 2206A

RULE 2206A FORM

In Re: Estate of ___________, : In the Court of Common Pleas

Deceased: Dauphin County, Pennsylvania

:

:

: No.

ORDER

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

Petition to Settle Wrongful Death and Survival Actions, 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 defendant(s).

The settlement proceeds shall be distributed as follows:

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

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

The balance of the settlement is apportioned as follows:

Wrongful Death Action $_______________

TO: (spouse)

TO: (child)

TO: (other)

Survival Action $_______________

TO: _______________, personal representative of the Estate of ____________.

BY THE COURT:

__________________________

J.