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
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
