Mc 350Ex Form – Fill Out and Use This PDF

MC-350EX

ATTORNEY OR PARTY WITHOUT ATTORNEY	STATE BAR NUMBER:		FOR COURT USE ONLY
NAME:
FIRM NAME:
STREET ADDRESS:
CITY:	STATE:	ZIP CODE:
TELEPHONE NO.:	FAX NO.:
EMAIL ADDRESS:
ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NAME:	CASE NUMBER:

PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF			No hearing date is requested.
			HEARING DATE:
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT
FOR MINOR OR PERSON WITH A DISABILITY			DEPT.:	TIME:

NOTICE TO PETITIONER

You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) 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) disposition of the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600–3613.) You may request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and either 3g(1) or 3g(2), below, are true and accurate; and (3) the court does not otherwise order.

If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing.

1.Petitioner (name or pseudonym*):

is the (check all boxes that apply):

Parent

Guardian ad litem*

Guardian

Conservator

Other (specify relationship):

of the claimant identified in item 2. (*Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ. Proc., § 372.5.))

2.Claimant (name): a. Address:

b. Date of birth:

c. Age:

d.

Minor

or

Person with a disability

(If the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.))

e.		Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order.
f.		Does not have a conservator of the estate.

3.Qualification for Expedited Approval

a.The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another.

b.No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust.

c.There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.

d.Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier.

e.Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.

f.All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court has made a final determination that all settling parties entered into the settlement in good faith.

g. (1)		The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and
		12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or
(2)		The settlement described in item 11 represents payment of the single-person policy limits of all liability insurance
		policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of
		those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in

Attachment 3.)

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MC-350EX

4. Claim The claim of the minor or adult person with a disability:
a.		Is not the subject of a pending action or proceeding. (Complete items 5–23.)
b.		Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5–23.)
	Name of court:
	Case no.:		Trial date:
c.		Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the
		defendants named below in the amount (exclusive of interest and costs) of (specify):		$

Defendants (names:

		Additional defendants listed on Attachment 4.			The judgment was filed on (date):
	(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13–23.)
5. Incident or accident			The incident or accident occurred as follows:
a. Date:			Time:

b.Place:

c.Persons involved (names):

Additional persons listed on Attachment 5.

6.Nature of incident or accident

The facts, events, and circumstances of the incident or accident are (describe what happened):

Continued on Attachment 6.

7.Injuries

The following injuries were sustained by the claimant as a result of the incident or accident (describe):

Continued on Attachment 7.

8.Treatment

The claimant received the following care and treatment for the injuries described in item 7 (describe):

Continued on Attachment 8.

MC-350EX [Rev. January 1, 2021]

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PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350EX

CASE NAME:

CASE NUMBER:

9.Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 9. A new report is not necessary if a previous report accurately describes the claimant's current condition.)

a. The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent injuries.

b. 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 and symptoms):

11.Amount and terms of settlement

To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant:

a. The total amount offered by all defendants named below is (specify):			$
b. The defendants and amounts offered by each are as follows (specify):
		Defendants (names)	Amounts
			$
			$
			$
			$
		Additional defendants and amounts offered are listed on Attachment 11b.

c.The terms of settlement are described on Attachment 11c. (If the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.)

12.Settlement payments to others

MC-350EX [Rev. January 1, 2021]

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PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350EX

13.Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to be paid or reimbursed from the proceeds of the settlement or judgment

a. Totals

	(1)	Total medical expenses before any reductions:						$
	(2)	Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare):						($	)
	(3)	Total of negotiated, contractual, or statutory reductions, if any:						($	)
	(4)	Total amount of medical expenses to be paid or reimbursed from proceeds:						$
	(5)	Total amount of statutory or contractual liens, if any:						$
	(Identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5)
	in Attachment 13a.)
b.	(1)		None of the claimant's medical expenses have been paid by Medicare.
	(2)		Medicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights,
			Medicare will be reimbursed in the amount of:					$
		(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(2).)
c.	(1)		None of the claimant's medical expenses have been paid by Medi-Cal.
	(2)		Medi-Cal paid some or all of claimant's medical expenses.
		(a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.)
							was filed in this matter on (date):
			A copy of the notice and proof of delivery		is attached
		(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 13c(2).)
d.		The claimant's health plan is requesting reimbursement for medical expenses paid under the plan.
		In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of:						$
	(Attach statements from the plan showing expense payments and requesting reimbursement.)
e.		Petitioner has paid claimant's medical expenses to be reimbursed in the amount of:						$
	(See instructions for item 15.)
f.	(1)		There are no statutory or contractual liens for payment of the claimant's medical expenses.
	(2)		There are one or more liens from medical service providers for payment of the claimant's medical expenses.
			In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of:					$

g.(Select (1) or (2) below.)

(1)		Latest statements from all medical service providers are attached as Attachment 13g.
(2)		All medical expenses have been paid by private insurance, Medicare, or Medi-Cal.

14.Claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment

a. Total amount of attorney's fees for which court approval is requested:$

(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. Include a copy of any written attorney fee agreement in Attachment 14a.)

b.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 or reimbursed out of claimant's share of the proceeds of the settlement or judgment:

MC-350EX [Rev. January 1, 2021]

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PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350EX

15.Reimbursement of fees and expenses paid by petitioner

(1)		Medical expenses listed in item 13:	$
(2)		Attorney's fees included in the total fee amount shown in item 14a:	$
(3)		Other expenses included in the total shown in item 14b:	$
(Attach proofs of the fees and expenses incurred and payments made, e.g., bills or invoices,			Total: $
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
16. Net balance of proceeds remaining for claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
after payment or reimbursement of all requested fees and expenses is (specify):			$

17.Summary

a.	Gross amount of proceeds of settlement or judgment for claimant:	$
b.	Medical expenses to be paid from proceeds of settlement or judgment:	$
c.	Attorney's fees to be paid from proceeds of settlement or judgment:	$
d.	Expenses (other than medical) to be paid from proceeds of settlement
	or judgment:	$
e.	Total fees and expenses to be paid from proceeds of settlement or
	judgment (add (b), (c), and (d)):	($	)

f.Balance of proceeds of settlement or judgment available for claimant

after payment of all fees and expenses (subtract (e) from (a)):	$

18.Information about attorney representing or assisting petitioner

a.

The attorney

is not

is representing or employed by another party involved in this matter.

(If you answered "is," identify the other party and explain the relationship in Attachment 18a. If the other party is a defendant,

you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1

and Cal. Rules of Court, rule 7.950.5(a)(6).)

b.

The attorney

has neither received nor expects to receive

has received or expects 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 ''has received or expects to receive,'' identify the person who paid or will pay the fees or other

compensation, the amounts paid or to be paid, and the dates of payment or expected payment):

Amount

From Whom Paid or Expected (name)

Date Paid or Expected

Paid or Expected

$

$

$

$

$

$

$

Continued on Attachment 18b.

Total: $

MC-350EX [Rev. January 1, 2021]

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PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350EX

19.Disposition of balance to claimant (check either a or b, then check each option requested and enter amount(s)):

MC-350EX [Rev. January 1, 2021]

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PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

MC-350EX

Date:

(TYPE OR PRINT NAME OF CLAIMANT)	(SIGNATURE OF CLAIMANT)

22.Petitioner recommends the proposed compromise, settlement, or disposition of judgment proceeds for the claimant to the court as being fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise, settlement, or disposition and make any other orders that are just and reasonable.

23.Number of pages attached:

Date:

(TYPE OR PRINT NAME)

(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:

(TYPE OR PRINT NAME OF PETITIONER)

(SIGNATURE OF PETITIONER)

MC-350EX [Rev. January 1, 2021]

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PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY