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Qualified Assignment and Release Agreement <br />In Accordance With <br />Interna! Revenue Code Section 130 <br />"Claimant(s)": Derek Canepa, a minor, by and through his Guardian ad Litem, Maria Guadalupe Garcia <br />City of Santa Ana <br />"Assignor": » <br />"Settlement Agreement": _ <br />[Exact title of Settlement Agreement orOrderj <br />"Governing Law": <br />"Assignee": F3HC'i STRUCTllPLI? 3114"F'LE'D7G;NT3TNC. <br />"Annuity Issuer": BERKSHIRE HATHAWAY LIFE INSURANCE COMPANY OF NEBRASKA <br />"Effective Data,,: <br />"Payee(s)":As shown in Addendum No. 1, uescri. tion of Periodic Payments <br />Annuity Contract No: <br />This Qualified Assignment and Release <br />Agreement ("Agreement") 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. Claimant(s) 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 Claimant(s) <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 of Section <br />130(c) of the Internal Revenue Code of <br />1908, 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, therefore, 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 />2. Nature of Periodic Payments. The Periodic <br />Payments constitute: <br />i, damages (other then punitive damages), <br />whether by suit or agreement, or <br />ii. compensation under a workers' <br />compensation act, <br />on account of personal injury or sickness in <br />a case invoivipg 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 greater than the liability of Assignor as <br />SS -1000 (12/2013) (Si Page 1 of 6 <br />