New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter VII - Surrogate's Court Forms › Subchapter A - Forms Authorized By Section 207.52 › Surrogate's Forms › Form WD-6 - Waiver and consent for individual

Current through Register Vol. 46, No. 28, July
					 10, 2024
Form WD-6
(Waiver and Consent for Individual)
SURROGATE'S COURT OF THE STATE OF NEW
						YORK
COUNTY ________
________x
In the Matter of the Application of
________, as Administrat________ of the
						Goods,
Chattels and Credits which were of
________ WAIVER AND CONSENT
deceased, File No. ________
for leave to compromise a certain cause of
						action for wrongful death of the decedent and to render and have judicially
						settled an account of the proceedings as such
Administrat________.
________x
TO THE SURROGATE'S COURT:
The undersigned, ________, being over the
						age of 21 years, having been born on ________, 19 ________, and residing at
						________, New York, being a person interested as a child of the decedent,
						hereby appears and waives the issuance and service of a citation in the above
						proceeding and consents to the following relief:
THAT the account of the proceedings of
						________ as administrat________ of the estate of ________, deceased, a copy of
						which is attached, should be judicially settled, and
THAT the administrat________ should be
						empowered to compromise and settle a certain claim for wrongful death against
						________for the sum of $ ________ and to discontinue any claim for conscious
						pain and suffering, and
THAT the provisions of the limited Letters
						of Administration issued to the petitioner on________ 19 ________, restraining
						the compromise or collecting upon the aforesaid claim and cause of action
						should be modified to permit said compromise, and
THAT the filing of a bond should be
						dispensed with, and
THAT the defendant, ________, or
						defendant's insurance company should pay to ________, Esqs., out of the
						proceeds of the settlement for the claim for wrongful death, the sum of $
						________ as and for attorneys' fees together with disbursements in the sum of $
						________, and
THAT the entire recovery of $ ________
						should be allocated to the cause of action for decedent's wrongful death,
						and
THAT the balance of the settlement, to wit
						the sum of $ ________, should be distributed to those distributees having
						sustained a pecuniary loss as follows: ________ % of the balance to ________,
						widow/widower of decedent; ________ % of the balance to ________, child of
						decedent; ________ % of the balance to ________, child of decedent; and
THAT the claim of ________ should be
						rejected, as a nondistributee, and
THAT the claim of ________ in the amount
						of $ ________ should be rejected, and
THAT, upon the payments as hereinbefore
						mentioned, the said ________ should be permitted to execute and deliver general
						releases and all other necessary papers to the defendant, ________, or
						defendant's insurance company, releasing them from all claims against them
						arising out of the aforesaid action for wrongful death, together with any other
						papers necessary to effectuate the said compromise, and
THAT the entire settlement be considered
						as a settlement for a cause of action for wrongful death and a waiver of my
						right to receive any distributee share of the settlement; and
Dated: ________, 19________
						________
STATE OF NEW YORK)
ss.:
COUNTY OF ________)
On the ________ day of ________, 19
						________, before me personally came ________, known to me to be the person who
						is described in the foregoing Waiver and Consent, and acknowledged to me that
						________ executed the same.
______________
Notary Public