STATE OF MICHIGAN

JUDICIAL CIRCUIT
JUDICIAL DISTRICT

REQUEST FOR APPROVAL OF BOND AND
NOTICE

SETTLEMENT/JUDGMENT
WRONGFUL DEATH SETTLEMENT

Original - Court
1st copy - Probate court

2nd copy - Defendant
3rd copy - Plaintiff

CASE NO.

Approved, SCAO

Court  address

Plaintiff name

Court  telephone  no.

Defendant name

Plaintiff's attorney, bar no., address, and telephone no.

Defendant's attorney, bar no., address, and telephone no.

v

Instructions:  This form must be used in all settlements/judgments and/or wrongful death settlements when the plaintiff or person receiving a distribution is a
legally incapacitated individual, a developmentally disabled person, a protected person, or a minor unless the payment to that minor is for not more than $5,000
in any single year during his or her minority and no conservator has been appointed for that minor.  If a settlement/judgment provides for creation of a trust, the
trust shall not be funded without the approval of the trust by the probate court in accordance with MCR 2.420(B)(5).

Plaintiff's Counsel:  After the circuit/district court judge completes the Request, take it to the probate court  to obtain written verification that the bond is approved
and that the bond, if any, has been filed with the probate court.  The Request will be presented to the probate judge assigned to the probate case.  Once the
probate judge signs the Notice of Bond Approval, the entire form will be returned to you for filing with the circuit/district court.  Dispositive orders will be entered
by the circuit/district court judge only after the Notice of Bond Approval has been filed.

Defense Counsel:  Forward the settlement/judgment draft to plaintiff's counsel after you receive a true copy of the judgment, consent judgment, or order of
dismissal.

REQUEST FOR BOND APPROVAL

Name of probate judge assigned to probate case

Name (not the deceased person or the personal representative of the estate)

,

County

a legally incapacitated individual

a minor

Probate case name and file number

resolving a wrongful death action.

1.

a. I have conducted a hearing in accordance with MCL 600.2922(6)(a) for the purpose of approving the distribution of funds

b. I have conducted a hearing in accordance with MCR 2.420(B) for the purpose of approving terms of a proposed settlement.

2. I approved

full

partial settlement/judgment in the amount of $

3.

Name of fiduciary

, the person serving as the fiduciary (guardian or conservator),

is receiving no funds, individually, from the settlement/judgment.

is receving $

.

.

4. The fiduciary will receive $

after costs and attorney fees.

for the estate of

Name of legally incapacitated individual or minor

5. A trust

is to be created under the terms of the settlement/judgment.

is not to be created.

Circuit/District judge

NOTICE OF BOND APPROVAL

The required bond has been approved by this court and has been filed as appropriate.

In lieu of bond, this court has approved a written agreement in regard to use of funds that all assets shall be placed in a restricted
account with no withdrawals or transfers to be made without probate court approval.

TO:

RE:

Date

Date

MC 95   (3/06)   REQUEST FOR APPROVAL OF BOND AND NOTICE

(SETTLEMENT/JUDGMENT/WRONGFUL DEATH SETTLEMENT)

Probate judge

    ,

Bar no.

Bar no.

MCR 2.420