Wrongful Death Settlement Allocation

WRONGFUL DEATH SETTLEMENT ALLOCATION

Allocation of Settlement Proceeds Among Beneficiaries

PART 1: CASE INFORMATION

A. Decedent Information

Decedent Name: [________________________________]
Date of Birth: [________________________________]
Date of Death: [________________________________]
Date of Incident: [________________________________]
Cause of Death: [________________________________]

B. Estate Information

Estate Case Number: [________________________________]
Court: [________________________________]
Personal Representative: [________________________________]
Date Letters Issued: [________________________________]

C. Settlement Information

Defendant(s): [________________________________]
Gross Settlement: $[________________________________]
Settlement Date: [________________________________]

PART 2: STATUTORY BENEFICIARIES

A. Surviving Spouse

☐ No surviving spouse

☐ Surviving spouse:

Name: [________________________________]
Date of Birth: [________________________________]
Date of Marriage: [________________________________]
Length of Marriage: [________________________________]

B. Surviving Children

☐ No surviving children

☐ Surviving children:

C. Surviving Parents

☐ No surviving parents
☐ Not statutory beneficiaries in this jurisdiction

☐ Surviving parents:

D. Other Statutory Beneficiaries

☐ None

☐ Other beneficiaries:

PART 3: ALLOCATION BETWEEN SURVIVAL AND WRONGFUL DEATH CLAIMS

A. Components of Settlement

B. Survival Action Breakdown

Survival Action Amount: $[________________________________]

This amount represents:

C. Wrongful Death Breakdown

Wrongful Death Amount: $[________________________________]

This amount represents:

D. Basis for Allocation

The allocation between survival and wrongful death claims is based on:

☐ Relative value of claims at trial
☐ Jury verdict allocation
☐ Mediation allocation
☐ Agreement of the parties
☐ Court determination
☐ Other: [________________________________]

Explanation:
[________________________________]
[________________________________]

PART 4: ALLOCATION AMONG WRONGFUL DEATH BENEFICIARIES

A. Factors Considered in Allocation

The following factors were considered in allocating wrongful death proceeds:

Surviving Spouse:
☐ Length of marriage
☐ Financial dependency
☐ Loss of consortium
☐ Age and health
☐ Other: [________________________________]

Children:
☐ Age and dependency
☐ Minor status
☐ Relationship with decedent
☐ Loss of parental guidance
☐ Financial support received
☐ Other: [________________________________]

Parents:
☐ Financial dependency
☐ Relationship with decedent
☐ Support provided by decedent
☐ Other: [________________________________]

B. Proposed Allocation

Wrongful Death Amount to Allocate: $[________________________________]

C. Justification for Allocation

[Explain the basis for the proposed allocation among beneficiaries]

Spouse Allocation Justification:
[________________________________]
[________________________________]

Children Allocation Justification:
[________________________________]
[________________________________]

Other Beneficiary Justification:
[________________________________]
[________________________________]

PART 5: DEDUCTIONS

A. Attorney Fees

B. Costs and Expenses

C. Liens

D. Funeral and Burial Expenses

☐ Paid by estate - reimbursed from survival action
☐ Paid by beneficiary [________] - reimbursed from wrongful death

PART 6: NET DISTRIBUTION SUMMARY

A. Survival Action Distribution

B. Wrongful Death Distribution

PART 7: SPECIAL CONSIDERATIONS

A. Minor Beneficiaries

☐ No minor beneficiaries

☐ Minor beneficiaries - Court approval required

Minor Settlement Petition Filed: ☐ Yes ☐ Pending
Case Number: [________________________________]

B. Incapacitated Beneficiaries

☐ No incapacitated beneficiaries

☐ Incapacitated beneficiaries:

C. Medicare Considerations

Decedent's Medicare Status:

☐ Decedent was not a Medicare beneficiary

☐ Decedent was a Medicare beneficiary

• Medicare conditional payments: $[________]
• Allocated to survival action (where medical claimed): ☐ Yes ☐ No
• Medicare recovery limited to survival allocation: ☐ Yes ☐ No

Impact of Allocation on Medicare:

If wrongful death claim did not include claim for medical expenses, Medicare's recovery may be limited. (See Bradley v. Sebelius, 11th Cir.)

Explanation: [________________________________]

D. Tax Considerations

Tax Advisor Consulted: ☐ Yes ☐ No ☐ Recommended

PART 8: BENEFICIARY CONSENT

A. Consent to Allocation

We, the undersigned beneficiaries, have reviewed the proposed allocation and:

☐ CONSENT to the allocation as proposed

☐ DO NOT CONSENT (explain objection): [________________________________]

B. Beneficiary Signatures

Beneficiary 1:
Name: [________________________________]
Relationship: [________________________________]
Signature: _________________________________ Date: ______________

Beneficiary 2:
Name: [________________________________]
Relationship: [________________________________]
Signature: _________________________________ Date: ______________

Beneficiary 3:
Name: [________________________________]
Relationship: [________________________________]
Signature: _________________________________ Date: ______________

Beneficiary 4:
Name: [________________________________]
Relationship: [________________________________]
Signature: _________________________________ Date: ______________

PART 9: COURT APPROVAL (if required)

☐ Court approval not required

☐ Court approval required due to:
☐ Minor beneficiaries
☐ Incapacitated beneficiaries
☐ Disputed allocation
☐ Statutory requirement
☐ Other: [________________________________]

Court Approval:
Case Number: [________________________________]
Hearing Date: [________________________________]
Order Signed: [________________________________]

PART 10: DISTRIBUTION AUTHORIZATION

A. Authorization

The Personal Representative and beneficiaries authorize distribution of settlement proceeds as set forth in this Allocation.

B. Release of Funds

Upon execution of releases and satisfaction of all liens, funds shall be distributed as follows:

PART 11: SIGNATURES

PERSONAL REPRESENTATIVE:

Signature: _________________________________ Date: ______________

Printed Name: [________________________________]

Title: Personal Representative of Estate of [DECEDENT]

ATTORNEY:

Signature: _________________________________ Date: ______________

Printed Name: [________________________________]

State Bar Number: [________________________________]

ATTACHMENT A: DETAILED ALLOCATION WORKSHEET

[Attach detailed calculations if complex]

ATTACHMENT B: BENEFICIARY DECLARATIONS

[Attach declarations supporting allocation]

ATTACHMENT C: COURT ORDER (if applicable)

[Attach court order approving allocation]