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SHC-PB-07 (Rev. 01
/01/2020)
Please visit our Self-Help Portal at: https://selfhelp.occourts.org
LamoreauxJusticeCenter
Room C-190
341TheCityDrive
Orange,CA
HarborJusticeCenter
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oom107,Self‐HelpWindow
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NewportBeach,CA
Cen
tralJusticeCenter
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700CivicCenterDrive
SantaAna,CA
SuperiorCourt
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viceCenter
27573PuertaReal
MissionViejo,CA
NorthJusticeCenter
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oom355
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Fullerton,CA
WestJusticeCenter
1
st
Floor
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Westminster,CA
SUPERIOR COURT OF CALIFORNIA
COUNTY
OF ORANGE
SELF-HELP CENTER
www.occourts.org/self-help
MINOR'S COMPROMISE
The Self-Help Center provides a free document review
service. To obtain an appointment to have your documents
reviewed, you must first fully complete the forms.
Pleaseuseblackink.
Self-Help Center Locations:
MC-350
FOR COURT USE ONLY
CASE NUMBER:
CASE NAME:
HEARING DATE:
PETITION TO APPROVE:
DEPT.: TIME:
Person With a DisabilityMinor
Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor,
(2) the compromise of a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a
party, or (3) the disposition of the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob.
Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or
examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment,
and hospitalization. The court may consider on an expedited basis without a hearing requests for approval of the compromises of
certain claims and actions or the disposition of the proceeds of certain judgments. If your claim, action, or judgment qualifies for
expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule
7.950.5.
Petitioner (name):
Claimant (name):
Address:
Date of birth: Age: Sex: e.
Minor Person with a disability
Relationship Petitioner's relationship to the claimant (check all applicable boxes):
Page 1 of 10
Form Adopted for
Alternative Mandatory Use
Judicial Council of California
MC-350 [Rev. January 1, 2011]
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
FAX NO. (Optional):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
Code of Civil Procedure, § 372 et seq.;
Probate Code, § 3500 et seq.;
Cal. Rules of Court, rules 3.1384,
7.101, 7.950, 7.951
www.courts.ca.gov
TELEPHONE NO.:
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
a.
b.
c.
d.
e.
f.
COMPROMISE OF PENDING ACTION
DISPOSITION OF PROCEEDS OF JUDGMENT
1.
2.
a.
b. c. d.
Parent
Guardian ad litem
Guardian
Conservator
(If you checked item 3e or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate
Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not
have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.)
g.
Disabled adult claimant is a petitioner. (See instructions for items 3e and 3f below.)
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f.
Other relationship (specify:)
The claim of the minor or adult person with a disability:
Case no.: Trial date: (Complete items 5–23.)
Name of court:
Has not been filed in an action or proceeding. (Complete items 5–23.)
Is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
a.
b.
COMPROMISE OF DISPUTED CLAIM
NOTICE TO PETITIONERS:
4. Nature of claim
3.
CASE NAME:
CASE NUMBER:
Page 2 of 10
MC-350 [Rev. January 1, 2011]
4.
Nature of claim
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13–23.)
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
c.
The judgment was filed on (date):
Is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against
the defendants named below in the total amount (exclusive of interest and costs) of (specify below):
Defendants (names)
$
Continued on Attachment 7.
Continued on Attachment 8.
7.
8.
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe):
Continued on Attachment 6.
6.
The claim of the minor or adult person with a disability:
Place:
Persons involved (names):
5.
Continued on Attachment 5.
a. Date and time:
b.
c.
Incident or accident The incident or accident occurred as follows:
Additional defendants listed on Attachment 4.
CASE NAME:
CASE NUMBER:
Page 3 of 10
MC-350 [Rev. January 1, 2011]
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
a.
9.
The claimant has recovered completely from the effects of the injuries described in item 7, and there are no
permanent injuries.
Extent of injuries and recovery
The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries):
b.
Continued on Attachment 9b.
The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries):
c.
Continued on Attachment 9c.
10. Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or
accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Petitioner fully understands that if the compromise proposed in this
petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further
recovery of compensation from the settling defendants named below even though the claimant's injuries may in
the future appear to be more serious than they are now thought to be.
Amount and terms of settlement
By way of settlement, the defendants named below have offered to pay the following sums to the claimant:
Amounts
Defendants (names)
The terms of settlement are as follows (if the settlement is to be paid in installments, both the total amount and the
present value of the settlement must be included):
Continued on Attachment 11.
11.
Defendants and amounts offered continued on Attachment 11.
$
$
$
$
$
a.
b.
The total amount offered by all defendants named below is (specify): $
The defendants and amounts offered by each are as follows (specify):
c.
(An original or a photocopy of all doctors' reports containing a diagnosis of and prognosis
for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 9.
A new report is not necessary so long as a previous report accurately describes the claimant's current condition.)
CASE NAME:
CASE NUMBER:
Page 4 of 10
MC-350 [Rev. January 1, 2011]
13.
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
Settlement payments to others
a.
12.
No defendant named in item 11b has offered to pay money to any person or persons other than the claimant to
settle claims arising out of the same incident or accident that resulted in the claimant's injury.
b. By way of settlement, one or more defendants named in item 11b have also offered to pay money to a person or
persons other than claimant to settle claims arising out of the same incident or accident that resulted in the
claimant's injury.
The total amount offered by all defendants to others (specify): $
Petitioner would receive money under the proposed settlement.
(1)
(2)
Amounts
Other plaintiffs or claimants (names)
Additional plaintiffs or claimants and amounts are listed on Attachment 12.
$
$
$
$
The settlement payments are to be apportioned and distributed as follows:
(3)
(4)
(5)
Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 12.
Petitioner
is not is a claimant against the recovery of the claimant (other than for
reimbursement for expenses paid by petitioner and listed under item 15).
(If you answered "is," explain in Attachment 12 the circumstances and the effect your claim has on the
proposed compromise of the claim described in this petition.)
Petitioner is not is a plaintiff in the same action with the claimant.
(If you answered "is," explain in Attachment 12 the circumstances and the effect your claim and its disposition
has on the proposed compromise of the claim or action described in this petition.)
(6)
Total outstanding medical expenses to be paid from the proceeds:
Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds:
a. Totals
(1)
(2)
(3)
$
$
(1)
(2)
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
Paid by petitioner in the amount of:
Paid by private health insurance or a self-funded plan under:
No reimbursement is requested by the plan.
(a)
(b)
(c)
(d)
(e)
(f)
(i)
(ii)
Reimbursement is to be made to the plan and:
(A)
(B)
(C)
There is a contractual reduction of $ (
$
for a total reimbursement to the plan in the amount of:
)
$
There is a negotiated reduction of $ (
)
No reduction has been agreed to,
Total medical expenses: $
An Employee Retirement Income Security Act (ERISA) insured plan.
An ERISA self-funded plan.
A Non-ERISA insured plan.
A Non-ERISA self-funded plan.
Amount paid by plan: $
Amount of reimbursement to the plan from proceeds of settlement or judgment:
CASE NAME:
CASE NUMBER:
MC-350
Page 5 of 10MC-350 [Rev. January 1, 2011]
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
(a)
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(4)
Paid by Medi-Cal in the amount of $
(a)
(b)
In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $
(Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 13b(4).)
Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code
section 14124.76 and:
The amount of the lien in dispute is: $
(i)
(ii)
Is filing a motion seeking a reduction of the lien concurrently with this petition.
Requests that the court reserve jurisdiction over this issue.
(5)
$of their lien claims, the lienholders have agreed to accept the total sum of:
13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
Notice of this claim or action has not been given to the State Director of Health Care Services.
(Explain why notice has not been given in Attachment 13b(4).)
and Institutions Code section 14124.73. A copy of the notice and proof of its delivery is attached.
was filed in this matter on (date):
(d)
(c)
(Provide requested information on each lienholder and certain other medical service providers below.)
(3)
Paid by Medicare in the amount of: $
less the statutory reduction in the amount of: $ (
)
for a total reimbursement to Medicare in the amount of:
$
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(3).)
The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all
or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any;
and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows:
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
(i) Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
(b)
Continued on Attachment 13b(5). (Provide information about additional providers in the above format,
including providers paid or to be paid by petitioner for which reimbursement is requested in item 13b(1)
above. You may use form MC-350(A-13b(5)) for this purpose.)
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
(ii) Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
There are one or more statutory or contractual liens of medical service providers for payment of medical
expenses. The total amount claimed under these liens is: $ . In full satisfaction
Page 6 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
$
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement or judgment
Items
Payees (names) Amounts
Continued on Attachment 14b.
14.
The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment:
a.
b.
Total amount of attorney's fees for which court approval is requested: $
$
$
$
$
$
$
$
$
$
$
$
Total: $
(If fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request, including
a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Respond to item 18a(2) on page 7 and
attach a copy of any written attorney fee agreement as Attachment 18a.)
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
16.
$
Net balance of proceeds for the claimant
after payment of all requested fees and expenses is:
15. Reimbursement of expenses paid by petitioner
Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested.
a.
b.
Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which
reimbursement is requested.
(1)
(2)
(3)
$
$
$
Total: $
Medical expenses listed in item 13:
Attorney's fees included in the total fee amount shown in item 14a:
Other expenses included in the total shown in item 14b:
(Attach proofs of the expenses incurred and payments made or obligations to pay incurred, e.g., bills or invoices,
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
17. Summary
Gross amount of proceeds of settlement or judgment for claimant:
Expenses (other than medical) to be paid from proceeds
of settlement or judgment:
Medical expenses to be paid from proceeds of settlement
or judgment:
Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (e) from (a)):
a.
Attorney's fees to be paid from proceeds of settlement or
judgment:
e.
b.
c.
d.
f.
$
$ (
$
Total of fees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c), and (d)):
$
$
$
)
Page 7 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
Information about attorney representing or assisting petitioner
a. Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with
respect to the claim asserted. (Go to item 19.)
(2)
The attorney who has represented or assisted petitioner is (name):
Telephone number:
The attorney
has not has received attorney's fees or other compensation in addition to that requested in this
petition for services provided in connection with the claim giving rise to this petition. (If you answered ''has,'' identify the person
who paid the fees or other compensation, the amounts paid, and the dates of payment):
Amounts
DatesFrom whom (names)
Continued on Attachment 18c.
18.
(1)
b.
State Bar number:
Law firm:
Address:
(2)
(3)
(4)
(1)
c.
$
$
$
$
$
do not asserted. Petitioner and the attorney
Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim
do have an agreement for services provided in
connection with the claim giving rise to this petition. (If you answered ''do,'' attach a copy of the agreement as
Attachment 18a, and complete items 18b.–18f.)
does notf. The attorney does expect to receive attorney's fees or other compensation in addition to that
requested in this petition for services provided in connection with the claim giving rise to this petition. (If you answered ''does,''
identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment):
From whom
(names) Amounts Expected dates
Continued on Attachment 18f.
$
$
$
$
$
The attorney
is not is representing or employed by any other party or any insurance carrier involved in the
matter. (If you answered "is," identify the party or carrier and explain the relationship in Attachment 18e.)
e.
The attorney did not did become concerned with this matter, directly or indirectly, at the instance of a party
against whom the claim is asserted or a party's insurance carrier. (If you answered ''did," explain the circumstances in
Attachment 18d.)
d.
Page 8 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
will be deposited in insured accounts in one or more financial
Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or
conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows
(check all that apply):
(a)
(3)
$
institutions in this state from which no withdrawals can be made without a court order.
The name, branch, and address of each depository are specified in Attachment 19a(3).
(b)
withdrawal only on order of the court. The terms and conditions of the annuity are specified in
Attachment 19a(3).
will be transferred to a custodian for the benefit of the minor under the
(c)
will be invested in a single-premium deferred annuity subject to
$
$
California Uniform Transfers to Minors Act. The name and address of the proposed custodian
and the property to be transferred are specified in Attachment 19a(3).
(d) will be transferred to the trustee of a trust that is either created by or
$
approved of in the order approving the settlement or the judgment given or to be given for the
minor. This trust is revocable when the minor attains the age of 18 years and contains all other
terms and conditions determined to be necessary by the court to protect the minor's interests. The
terms of the proposed trust and the property to be transferred are specified in Attachment 19a(3).
A copy of the (proposed) judgment is attached as Attachment 4c.
Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
19.
There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a
a.
disability filed in (name of court):
Case no.:
(1)
the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money
or other property is specified in Attachment 19a(1).
of the proceeds in money or other property will be paid or delivered to $
(2)
Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability.
Petitioner requests authority to deposit or invest $
property to be paid or delivered under 19a(1) with one or more financial institutions in this state or with a trust
company, subject to withdrawal only as authorized by the court. The money or other property and the name,
branch, and address of each financial institution or trust company are specified in Attachment 19a(2).
of the money or other
(e)
will be transferred to the trustee of a special needs trust under
$
Probate Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a
disability. The terms of the proposed special needs trust and the property to be transferred are
specified in Attachment 19a(3).
Page 9 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
19.
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
approved of in the order approving the settlement or the judgment given or to be given for the minor. This
trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions
determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and
the money or other property to be transferred are specified in Attachment 19b(7).
(7)
(9)
will be transferred to the trustee of a trust that is either created by or$
discretion determines is in the best interest of the minor or the adult person with a disability. The proposed
conditions and the property are specified in Attachment 19b(9).
of property other than money will be held on such conditions as the court in its $
A copy of the (proposed) judgment is attached as Attachment 4c.
is in the best interest of the minor or the adult person with a disability. The proposed conditions are specified
on Attachment 19b(8). (Value must not exceed $20,000.)
(8) of money will be held on such conditions as the court in its discretion determines $
(10)
Continued on Attachment 19.
will be paid or transferred to the adult person with a disability. The money or other
will be deposited with the county treasurer of the County of (name):
The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h).
$
$
property is specified in Attachment 19b(11).
(11)
Disposition of balance of proceeds of settlement or judgment (cont.)
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
Probate Code sections 3604 and 3611(c) for the benefit of the minor or the adult person with a disability.
The terms of the proposed special needs trust and the money or other property to be paid or transferred are
specified in Attachment 19b(4).
(4)
conditions specified in Probate Code sections 3401–3402, without bond. The name and address of the
parent and the money or other property to be delivered are specified in Attachment 19b(5). (Value of minor's
entire estate, including the money or property to be delivered, must not exceed $5,000.)
(5)
Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other
property to be transferred are specified in Attachment 19b(6).
(6)
will be transferred to a custodian for the benefit of the minor under the California
$
will be paid or delivered to a parent of the minor, upon the terms and under the
$
will be paid or transferred to the trustee of a special needs trust under
$
b. There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability.
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
(check all that apply):
(1)
A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability
(2)
institutions in this state, subject to withdrawal only upon the authorization of the court. The name,
branch, and address of each depository are specified in Attachment 19b(2).
$ of money will be deposited in insured accounts in one or more financial
to the person so appointed. The money or other property are specified in Attachment 19b(1).
will be appointed. $ of money and other property will be paid or delivered
(3)
withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified
in Attachment 19b(3).
$
of money will be invested in a single-premium deferred annuity, subject to
Page 10 of 10MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
21.
Petitioner requests the following additional orders (specify and explain):
Continued on Attachment 21.
Additional orders
Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to
the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise
settlement or proposed disposition and make such other and further orders as may be just and reasonable.
Number of pages attached:
Date:
(TYPE OR PRINT NAME OF ATTORNEY) (SIGNATURE OF ATTORNEY)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
22.
23.
(TYPE OR PRINT NAME OF PETITIONER)
(SIGNATURE OF PETITIONER)
Statutory liens for special needs trust
20.
Petitioner requests a court order for payment of funds to a special needs trust (explain how statutory liens under Probate
Code section 3604, if any, will be satisfied):
Continued on Attachment 20.
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CASE NAME:
CASE NUMBER:
MEDICAL SERVICE PROVIDER ATTACHMENT TO
PETITION TO APPROVE COMPROMISE OF CLAIM OR ACTION OR
DISPOSITION OF PROCEEDS OF JUDGMENT
(Miscellaneous)
MC-350(A-13b(5))
of
Form Approved for
Optional Use
Judicial Council of California
MC-350(A-13b(5))
[New January 1, 2010]
Code of Civil Procedure, § 372 et seq.;
Probate Code, § 3500 et seq.;
Cal. Rules of Court, rules 3.1384,
7.950, 7.951
www.courtinfo.ca.gov
MEDICAL SERVICE PROVIDER ATTACHMENT TO PETITION TO APPROVE COMPROMISE
OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT
(A person using Judicial Council form MC-350 to petition for court approval of the compromise of a claim of a minor or an action
involving a minor or person with a disability, or disposition of the proceeds of a judgment in favor of a minor or person with a disability,
must provide information about medical service providers that (1) have liens for payment of charges for medical care and treatment
provided to the minor or disabled claimant or (2) were paid (or will be paid from the proceeds) by petitioner for which petitioner
requests reimbursement from the proceeds of the compromise or judgment. (See item 13b(5) on page 5 of form MC-350.) One or
more copies of this form may be used as Attachment 13b(5) to that form to provide the required information about additional medical
service providers not listed in that form.)
Attachment 13b(5) to form MC-350
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or
any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner requests
reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any; and the amount
to be paid from the proceeds of the settlement or judgment to each provider are as follows:
13 b. (5) (b)
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
attached pages
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MC–351
FOR COURT USE ONLYATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FAX NO. (Optional):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
CASE NAME:
CASE NUMBER:
ORDER APPROVING:
Minor
Person With a Disability
1.
proposed compromise of a disputed claim of a minor or a pending action involving a minor or a person with a disability or a
proposed disposition of the proceeds of a judgment for a minor or a person with a disability.
Dept.:Time:
2.
3.
4.
The claim or action to be compromised is asserted, or the judgment is entered, against (name of settling or judgment defendant or
defendants (the "payer")):
Page 1 of 4
Form Adopted for Mandatory Use
Judicial Council of California
MC-351 [Rev. January 1, 2010]
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
Petitioner (name):
Claimant (name):
Defendant5.
Parent
Guardian ad litem
Guardian
Conservator
Claimant, an adult person with a disability, is the petitioner.
TELEPHONE NO.:
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
HEARING DATE, IF ANY:
DEPT.:
COMPROMISE OF DISPUTED CLAIM
COMPROMISE OF PENDING ACTION
DISPOSITION OF PROCEEDS OF JUDGMENT
CASE NUMBER:
a.
b.
c.
d.
e.
f.
Relationship to claimant
Petitioner has the following relationship or relationships to claimant (check all applicable boxes):
Judicial officer:
is a minor.
is a "person with a disability" within the meaning of Probate Code section 3603 who is:
a.
b.
Code of Civil Procedure, § 372;
Probate Code, § 3500 et seq.;
Cal. Rules of Court, rules 3.1384, 7.953
www.courtinfo.ca.gov
has petitioned for court approval of a
Other (specify):
Hearing
Date:
a.
No hearing was held. The petition is an expedited petition under rule 7.950.5 of the California Rules of Court.
b.
c.
(1)
An adult. Claimant's date of birth is (specify):
(a)
(b)
Without a conservator. Claimant has capacity to consent to this order, within the meaning of
Probate Code section 812, and has consented to this order.
A conservatee; a person for whom a conservator may be appointed; or without capacity to
consent to this order, within the meaning of Probate Code section 812.
(2)
A minor described in Probate Code section 3603(b)(3).
CASE NAME:
CASE NUMBER:
(c)
Payee (name):
Address:
Amount: $
Payee (name):
Address:
Amount: $
Continued on Attachment 7c(1)(c). (Provide information about additional payees in the above format.)
(d) Other authorized disbursements payable directly to third parties in the total amount of: $
(e)
Total allowance for fees and expenses from the settlement or judgment:
Page 2 of 4
MC-351 [Rev. January 1, 2010]
(b)
Medical, hospital, ambulance, nursing, and other like expenses payable directly to
providers as follows, in the total amount of:
Continued on Attachment 7c(1)(d).
(Describe and state the amount of each item and provide the name and address of each payee):
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
(i)
(ii)
(A)
(B)
(A)
(B)
$
$
Reimbursement for medical and all other expenses paid by the petitioner or the
petitioner's attorney in the total amount of:
$
MC–351
THE COURT ORDERS
The petition is granted and the proposed compromise of claim or action or the proposed disposition of the proceeds of the
The payer shall disburse the proceeds of the settlement or judgment approved by this order in the following manner:
7.
a.
c.
(1)
(a)
Attorney's fees in the total amount of: $ payable to (specify):
judgment is approved. The gross amount or value of the settlement or judgment in favor of claimant is $
Payment of fees and expenses
Fees and expenses shall be paid by one or more checks or drafts, drawn payable to the order of the petitioner and the
petitioner's attorney, if any, or directly to third parties entitled to receive payment identified in this order for the following
items of expense or damage, which are hereby authorized to be paid out of the proceeds of the settlement or judgment:
6.
THE COURT FINDS that all notices required by law have been given.
b.
Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under
Welfare and Institutions Code section 14124.76. The amount shown payable to the Department of Health Care Services
in item 7c(1)(d) of this order is the full amount of the lien claimed by the department but is subject to reduction on further
order of the court upon determination of the claim for reduction.
Page 3 of 4
MC-351 [Rev. January 1, 2010]
CASE NAME:
CASE NUMBER:
8.
Within 48 hours of receipt of a check or draft described in item 7c(2)(a), the petitioner and the petitioner's attorney, if
any, must deposit the check or draft in the petitioner's name as trustee for the claimant in one or more blocked accounts
at (specify name, branch, and address of each depository, and the amount of each account):
a.
Continued on Attachment 8a.
Further orders of the court concerning blocked accounts
The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked
account under item 7c(2)(a):
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC–351
drawn payable to the order of the petitioner as trustee for the claimant. Each such check or draft must bear an
endorsement on the face or reverse that it is for deposit in one or more interest-bearing, federally insured
accounts in the name of the petitioner as trustee for the claimant, and no withdrawals may be made from the
accounts except as provided in the Order to Deposit Money Into Blocked Account (form MC-355), which is
signed contemporaneously with this order (''blocked account").
Balance
The balance shall be disbursed as follows:
(a)
(b) By the following method(s) (describe each method, including the amount to be disbursed ):
If money is to be paid to a special needs trust under Probate Code section 3604, all statutory liens in favor
of the state Department of Health Care Services, the state Department of Mental Health, the state
Department of Developmental Services, and any city and county in California must first be satisfied by the
following method (specify):
(c)
Continued on Attachment 7c(2)(b).
Continued on Attachment 7c(2)(c).
The balance of the settlement or judgment available for claimant after payment of all allowed
fees and expenses is:
(2)
$
By one or more checks or drafts in the total amount of (specify): $
THE COURT ORDERS (cont.)
The payer shall disburse the proceeds of the settlement or judgment approved by this order in the following manner:
7.
c.
Authorization to execute settlement documents
The petitioner is authorized to execute settlement documents as follows (check only one):
9.
a. Upon receipt of the full amount of the settlement sum approved by this order and the deposit of funds, the
petitioner is authorized and directed to execute and deliver to the payer a full, complete, and final release and
discharge of any and all claims and demands of the claimant by reason of the accident or incident described in
the petition and the resultant injuries to the claimant and a properly executed dismissal with prejudice.
b. The petitioner is authorized and directed to execute any and all documents reasonably necessary to carry out
the terms of the settlement.
The petitioner is authorized and directed (specify):c.
Bond is not required.ordered and fixed in the amount of: $
A copy of this order shall be served on the payer forthwith.
Additional orders
The court makes the following additional orders (specify):
Date:
JUDICIAL OFFICER
Page 4 of 4
MC-351 [Rev. January 1, 2010]
Continued on Attachment 9c.
10.
11.
12.
Continued on Attachment 12.
SIGNATURE FOLLOWS LAST ATTACHMENT
ORDER APPROVING COMPROMISE OF DISPUTED CLAIM OR PENDING
ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR
MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
CASE NAME:
CASE NUMBER:
MC–351
The balance of the proceeds of the settlement or judgment deposited in a blocked account or accounts under item
7c(2)(a) may be withdrawn only as follows (check (1) or (2)):
(1)
No withdrawals of principal or interest may be made from the blocked account or accounts without a further
written order under this case name and number, signed by a judge, and bearing the seal of this court. The
money on deposit is not subject to escheat.
(2)
No withdrawals of principal or interest may be made from the blocked account or accounts without a further
written order under this case name and number, signed by a judicial officer, and bearing the seal of this
court, until the minor attains the age of 18 years. When the minor attains the age of 18 years, the depository,
without further order of this court, is authorized and directed to pay by check or draft directly to the former
minor, upon proper demand, all moneys including interest deposited under this order. The money on deposit
is not subject to escheat.
The blocked account or accounts belong to a minor. The minor was born on (date):
c.
8. Further orders of the court concerning blocked accounts
The court makes the following additional orders concerning any part of the balance ordered to be deposited in a blocked
account under item 7c(2)(a):
The petitioner and the petitioner's attorney, if any, must deliver to each depository at the time of deposit three copies of
the Order to Deposit Money Into Blocked Account (form MC-355), which is signed contemporaneously with this order,
and three copies of the Receipt and Acknowledgment of Order for the Deposit of Money Into Blocked Account (form
MC-356). The petitioner or the petitioner's attorney must file a copy of the receipt with this court within 15 days of the
deposit. The sole responsibilities of the petitioner and the petitioner's attorney, if any, are to place the balance in a
blocked account or accounts and to timely file a copy of the receipt.
b.
.
MC–355
ORDER TO DEPOSIT MONEY INTO BLOCKED ACCOUNT
1. The petition of (name):
to deposit funds in a blocked account oras (specify capacity):
blocked accounts came on for hearing on (date): at (time):
in Dept.:
THE COURT ORDERS
2. Money that belongs to (name):
shall be deposited in an interest-bearing, federally insured blocked account or accounts.
3. Each account shall indicate the name of the minor or other person who owns the account.
4. The total amount authorized for deposit, including any accrued interest, is: $
5. Withdrawals (check a or b):
a. No withdrawals of principal or interest shall be made from the blocked account or accounts without a written order under
this case name and number, signed by a judge, and bearing the seal of this court. The money on deposit is not subject
to escheat.
b.
No withdrawals of principal or interest shall be made from the blocked account or accounts without a written order under
this case name and number, signed by a judge, and bearing the seal of this court, until the minor attains the age of 18
years. When the minor attains the age of 18 years, the depository, without further order of this Court, is authorized and
directed to pay by check or draft directly to the former minor, upon proper demand, all moneys including interest
deposited under this order. The money on deposit is not subject to escheat.
6. The petitioner and the petitioner's attorney, if any, shall deliver a copy of this order to each depository in which funds are deposited
under this order. The depository's acknowledgment of receipt of the order and the funds shall be filed with this court within 15 days
of deposit.
Date:
JUDGE OF THE SUPERIOR COURT
Page 1 of 1
Code of Civil Procedure, § 372;
Form Adopted for Mandatory Use
Judicial Council of California
MC-355 [Rev. January 1, 2007]
Probate Code, § 3600, et seq.;
ORDER TO DEPOSIT MONEY INTO BLOCKED
ACCOUNT
Cal. Rules of Court, rules 3.1384, 7.953
www.courtinfo.ca.gov
FOR COURT USE ONLYATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):
TELEPHONE NO.: FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NAME:
CASE NUMBER:
The blocked account or accounts belong to a minor. The minor was born on (date):
MC–356
CASE NAME:
CASE NUMBER:
RECEIPT AND ACKNOWLEDGMENT OF ORDER FOR THE DEPOSIT OF
MONEY INTO BLOCKED ACCOUNT
(Attach a copy of the Order to Deposit Money Into Blocked Account to this receipt)
1. I acknowledge receipt of the Order to Deposit Money Into Blocked Account, a copy of which is attached.
2. The account described below in which funds have been deposited under the court's order is a federally insured, blocked account.
3. Name and title on the account:
4. Name of depository:
a. Branch:
b. Address:
5. Account number:
6. Date account opened:
7. Amount of initial deposit: $
8. Present balance: $
I certify that I am authorized to execute this receipt and acknowledgment, and that no withdrawal of principal or interest from this
account will be permitted without a signed court order under this case name and number, bearing the seal of this court.
Date:
(TYPE OR PRINT NAME) (AUTHORIZED SIGNATURE)
Title:
Page 1 of 1
Code of Civil Procedure, § 372;
Form Adopted for Mandatory Use
Judicial Council of California
MC-356 [Rev. January 1, 2007]
RECEIPT AND ACKNOWLEDGMENT OF ORDER FOR THE
DEPOSIT OF MONEY INTO BLOCKED ACCOUNT
Probate Code, § 3600, et seq.,
Cal. Rules of Court, rules 3.1384, 7.953
www.courtinfo.ca.gov
FOR COURT USE ONLY
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):
TELEPHONE NO. (Optional): FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
(for example, Proceedings to be covered
(TYPE OR PRINT NAME)
Cal. Rules of Court, rule 1.100
www.courtinfo.ca.gov
From to
For the above matter or appearance
For the following duration:
DEPARTMENT:
Applicant requests accommodation under rule 1.100 of the California Rules of Court, as follows:
MC-410
APPLICANT (name): FOR COURT USE ONLY
APPLICANT is Witness Juror OtherAttorney Party
Person submitting request (name):
APPLICANT'S ADDRESS:
TELEPHONE NO.:
NAME OF COURT:
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
JUDGE:
Special requests or anticipated problems (specify):
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
RESPONSE
requested accommodation, in whole
Indefinite period
Page 1 of 1
creates an undue burden on the court.
For the following reason (attach additional pages, if
necessary): [See Cal. Rules of Court, rule 1.100(g), for
the review procedure]
TITLE:
CASE NUMBER:
Date:
`
(SIGNATURE)
(TYPE OR PRINT NAME)
Date response delivered in person or sent to applicant:
WITH DISABILITIES AND RESPONSE
Date or dates needed (specify):
4. Impairment necessitating accommodation (specify):
5.
REQUEST FOR ACCOMMODATIONS BY PERSONS
WITH DISABILITIES AND RESPONSE
3.
6.
SIGNATURE FOLLOWS THE LAST PAGE OF THE RESPONSE.
(dates):
fundamentally alters the nature of the service,
program, or activity.
1. Type of proceeding: Criminal Civil
APPLICANT'S INFORMATION TO BE KEPT CONFIDENTIAL
(Specify)
bail hearing, preliminary hearing, sentencing hearing, family, probate, juvenile):
REQUEST FOR ACCOMMODATIONS BY PERSONS
(SIGNATURE)
2.
requested accommodation, in part (specify below):
CASE
Type or types of accommodation requested (specify):
The accommodation request GRANTED
the court will provide the
The accommodation is DENIED
because it
fails to satisfy the requirements of rule 1.100.
andis
trial,
Form Approved for Optional Use
Judicial Council of California
MC-410 [Rev. January 1, 2010]
Other:
The court will provide the alternative
accommodation as follows:
in whole or in part
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SUPERIOR COURT OF CALIFORNIA OF ORANGE COUNTY SELF-HELP (The Superior Court of California - County of Orange)

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Completed 8 February 2021

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