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Qualified Assignment and Release Agreement <br />In Accordance With <br />Internal Revenue Cote Section 130 <br />"C18117100 S)": N40892 Cottez, a minor, by and through bar Guardian Ad Litem Arturo Cortez <br />"Assignor"; California Charter Schools Joint Powers Authority DBA: CharterSAFE; City of Santa Ana; <br />State Farm Mutual Insurance Companies <br />"Settlement Agreemeni": <br />[Exact title of Settlement Agreement or Order] <br />"Governing L.arvv'": Oalffarnla <br />"Assignee": BEG ST11C7C?T'TRED ,">FTTS,B:NFETS, 7ttG. <br />"Annuity Issuer srrrstMIRF HATHAWAY UrE aasuzxsracrr coMznWT or NEBRA&KA <br />"Effective t WI, <br />"Payee($)"'.As shown in Addendun: No. 1, nesoriLt am of i�rri0d1c to tents <br />Annuity Contract No: <br />This Qualified Assignment and Release <br />Agreement CAgreement") Is made and entered <br />into as of the Effective Date by and among the <br />undersigned parties with reference to the <br />following facts: <br />A. Claimants) and Assignor are parties to or <br />are otherwise subject to the above - <br />referenced Settlement Agreement under <br />which Assignor has liability to make certain <br />periodic payments to the designated <br />Payee(s)-as specified in Addendum No. 1 of <br />this Agreement (the "Periodic Payments"), <br />Where no Payee(s) other than Claimants) <br />are shown in Addendum No. 1, it is <br />understood that any references herein to <br />Payee(s)shall apply to Claimant(s); <br />B. Assignor and Assignee wish to effect a <br />"qualified assignment" within the meaning <br />and subject to the conditions or Section <br />130(c) of the Internal Revenue Code of <br />1086, as amended (the "Code"). <br />C. This Agreement will be effective contingent <br />upon Assignee's receipt of the full premium <br />to fund the Periodic Payments contained <br />herein. <br />Now, thoreforo, in consideration of the <br />foregoing and for other good and valuable <br />consideration, the parties agree as follows: <br />1. Assignment and Assumption; Release of <br />Assignor. Assignor hereby assigns to <br />Assignee, and Assignee hereby accepts and <br />assumes, all of Assignor's liability to make <br />the Periodic Payments. Each Claimant <br />hereby accepts and consents to such <br />assignment by Assignor and assumption by <br />Assignee. Effective on the Effective Date, <br />each Claimant hereby releases and <br />discharges Assignor from all liability to make <br />the Periodic Payments, including the failure <br />of Assignee to make any of the Periodic <br />Payments and/or Annuity issuer to fund any <br />of the Periodic Payments for any reason <br />whatsoever. <br />g. Nature of Periodic Payments, The Periodic <br />Payments constitute: <br />i, damages (other than punitive damages), <br />whether by suit or agreement, or <br />H. compensation under a workers' <br />compensation act, <br />on account of personal injury or sickness in <br />a case involving physical injury or physical <br />Sickness, within the meaning of Sections <br />130(c) and 104(a) of the Code. <br />3. Extent of Assignee's Liability. Assignee's <br />liability to make the Periodic Payments shall <br />be no greeter than the liability of Assignor as <br />$$-1000 (12/2013) IS] Page 1 of <br />