Settlement/Trial Division Judge:_________________________	Court Term:_________________
Caption:___________________________________________	Number:____________________
Companion Cases (Indicate Court Term and Number):___________________________________
Any Pleadings filed in Orphans' Court: Yes No

Are the following items included in the Petition/Order:	Yes	No
1. Minor's/Incapacitated Person's:
a. Date of Birth
b. SS#
c. Address
d. Written approval of settlement if minor is 16 years of age or older
2. Parent(s)/guardian verification attached
3. If guardian od estate was appointed, is Order attached
4. Information concerning mother and father
5. Details concerning the injury
6. Doctor's report of present condition of minor/incapacitated person
7. Statement from parents and/or guardian certifying the condition of minor/incapacitated person and approval of proposed settlement
8. Counsel's reasons for approval of proposed settlement
9. Petition signed by counsel
10. Department of Welfare or any other entity lien or claim
11. Does the Order Contain the following:
a. Itemization of costs for reimbursement
b. Counsel fee computed on net settlement
c. Affidavit will be filed certifying compliance with the Order
d. Amount to minor/incapacitated person (in restricted accounts, typically if under $350,000)
e. Amount to Guardian of minor/incapacitated person (typically if over $350,000)
I verfiy the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers. 11-9_________________________________________________________