I. Estimating the Loss of Dependent Support and Loss of Net Accumulations to the Estate
A. Background Information:
Name of Decedent: |
||||
Race | Sex: |
Date of Birth: |
|||
Date of Mediation: |
Date of Trial: |
|||
Date of Incident: |
Date of Death: |
|||
B. Family Members Who Have Claim(s) for Loss of Financial Support and/or Loss of Services:
NAME |
RELATIONSHIP TO DECEDENT |
DATE OF BIRTH |
C. Copy of Complaint.
D. Earnings history: Copies of income tax returns for the five years prior to date of death including W-2 forms. If not available, please provide earnings verification from employer(s).
E. Occupational history: Name of employer(s) for at least five years prior to date of death, position held, years of service. For most recent employer, i.e. employer at time of death, please provide annual salary plus the value (dollar amount or percentage of gross salary) of any employer contributions to fringe benefit plans.
F. Educational attainment (and, in case of child, a verification of class standing via school records preferably). This is mandatory in cases where decedent has had no work record or work history is spotty.
G. Summary of Assets.
II. Loss of Household and/or Childcare Services
If a claim is being made for the loss of the decedent's services in and around the household, a statement will be required (from decedent's spouse and/or children), defining and delineating the nature and extent (number of hours per week, month or year) of services which the decedent had been providing.