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:	Yes	No
1. Verification from Administrator/Executor:
2. If guardian of estate was appointed, is Order attached
3. Notice letter to all parties in interest is attached
4. Counsel's reasons for approval of proposed settlement
5. Reasons for the allocation between wrongful death and survival action
6. Reason and amount of pecuniary loss suffered by each beneficiary of Wrongful Death Claim
7. Petition signed by counsel
8. Department of Welfare or any other entity claim or lien
9. Does the Order of Distribution set forth the following:
a. Itemization of costs for reimbursement
b. Counsel fee computed on net settlement
c. Wrongful Death Claim
i. Amount to spouse and adult children
ii. Amount to minor/incapacitated person (in restricted accounts, typically if under $350,000)
iii. Amount to Guardian of minor/incapacitated person (typically if over $350,000)
iv. Parent
d. Survival Claim: To Administrator/Executor of the Estate of the Deceased
e. Affidavit will be filed certifying compliance with the Order
I verfiy the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers. 11-10________________________________________________________