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-4 - Attorney's affidavit

Current through Register Vol. 46, No. 28, July
					 10, 2024
Form WD-4
(Attorney's Affidavit)
SURROGATE'S COURT OF THE STATE OF NEW
						YORK
COUNTY OF ________
________x
In the Matter of the Application of
________ as Administrat________ of the
						Goods,
Chattels and Credits which were of
- ATTORNEY'S
________, - AFFIDAVIT
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
STATE OF NEW YORK)
ss.:
COUNTY OF ________)
________, being duly sworn, deposes and
						says:
1. I am a member of the firm of ________
						Esqs., with offices at ________.
2. We were retained on ________, and filed
						a statement of retainer with the Office of Court Administration under Code
						Number ________.
3. After being retained by ________, the
						widow/widower of decedent, an extensive investigation was conducted into the
						occurrence that resulted in the death of decedent, including obtaining police
						reports, hospital records, motor vehicle bureau records, etc.
4. It was ascertained that on ________ at
						approximately ________ a.m./p.m. of that day at [location] ________ the
						decedent [describe details of accident] The decedent sustained multiple
						injuries and was taken to ________ Hospital, where he/she died at ________
						a.m./p.m. on ________ without having regained consciousness.
5. Thereafter a claim was made against the
						________ Insurance Company, which insured the vehicle of ________
6. The funeral and hospital bills were
						paid under no- fault benefits and none are left outstanding.
7. The insurance company of the defendant
						driver disclaimed any liability, claiming decedent [describe defendant's
						defense]
8. After intensive negotiations with
						________ Insurance Company, it finally has made an offer in the sum of $
						________ out of a total of $ ________coverage for the wrongful death of
						decedent.
9. All of the proceeds of the settlement
						of the claim are to be allocated to the action for wrongful death, the decedent
						never having regained consciousness following the occurrence complained
						of.
10. That ________ was, in addition
						thereto, appointed Guardian of the person and property of the infant, ________,
						by the Surrogate's Court, ________ County, on ________, under File No.
						________
11. In light of the fact that the owner of
						the vehicle involved in the accident alleges that the accident was the fault of
						the decedent and [provide other details] ________your deponent submits that the
						settlement is fair and reasonable and should be accepted for the best interests
						of the estate.
12. Your deponent will prepare all papers
						necessary to accomplish said settlement and obtain approval of the Surrogate's
						Court and do whatever is necessary on behalf of the estate and the next of
						kin.
13. The following expenses have been
						incurred [list all expenses]:
Police reports $ ________
Hospital records
Surrogate's Court fees
Motor Vehicle Bureau
TOTAL $ ________
14. Your deponent has not become concerned
						in this action at the request of the defendants or their attorneys or
						representatives, and no compensation has been or will be received by deponent
						from defendants or their attorneys or representatives. Any compensation to be
						received by way of fees herein is to be paid out of the proceeds of the
						proposed settlement and not otherwise. Your deponent has a written retainer
						with the administrat________ herein providing for a fee of ________% of the net
						recovery, which your deponent submits is fair and reasonable in light of all of
						the facts and circumstances.
15. On ________, your deponent caused a
						check of the records of this court to be made for liens, assignments and
						encumbrances and found none, and your deponent has been advised by petitioner
						that petitioner does not know of any filed or recorded, and your deponent has
						inquired of the petitioner and is satisfied that the only claims that have been
						filed with the administrat________ are those shown in the petition. Your
						deponent waives notice and the requirement that any security be filed and
						consents to the entry of a decree without any further notice.
16. No previous application for the relief
						requested herein has been made to any court or judge.
17. Your deponent requests that a fair and
						reasonable sum for services rendered and to be rendered be allowed in the sum
						of $ ________, together with disbursements in the sum of $ ________
WHEREFORE, deponent respectfully prays
						that the relief requested herein be granted.
________
Sworn to before me this
________ day of ________,
						19________.
______________
Notary Public