DECEDENT’S ESTATE

COURT OF COMMON PLEAS OF

ORPHANS’ COURT DIVISION

ESTATE OF , DECEASED

No.

PETITION FOR ADJUDICATION /
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. O.C. Rule 2.4

This form shall be used in all cases involving the Audit or Confirmation of the
Account of a Decedent’s Estate. If space is insufficient, riders may be attached.
Attach the papers required under items 1, 2, 4, 8, 10, 16-19, as applicable, and
any instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

Name of Counsel:

 

Supreme Court I.D. No.:

 

Name of Law Firm:

 

Address:

 

 

Telephone:

 

Fax:

 

Email:

 

Form OC-01 rev 01.01.20 Page 1 of 11
Estate of , Deceased

1. Name(s) and address(es) of Petitioner(s):
Petitioner: Petitioner:

Name:

 

 

Address:

 

 

 

 

Identify any Executors or Administrators who have not joined in the Petition
for Adjudication/Statement of Proposed Distribution and/or the Account and
state reason:

Is this the first accounting for this estate? ............. 0.00000. [| Yes [] No
If not, identify prior accountings, the accounting periods covered, and
the dates of adjudication of the prior accountings.

Pursuant to 20 Pa.C.S. § 3501.2, if property from a trustee, guardian, or agent
acting under a power of attorney is being received into the estate, an Account of
the administration of such trust, guardianship, or principal's estate may be
annexed to the Estate Account. Is any such Account annexed to this Estate
ACCOUN? 20 ccc cece e eee neeeunes -LJ Yes [] No

If so, the annexed Account and the appropriate fully completed Petition for

Adjudication/Statement of Proposed Distribution for the annexed matter should be
filed as Exhibits to this Petition.

2. Decedent died on

 

["]Letters Testamentary or [_] Letters of Administration were granted to Petitioner(s) on

 

Date of Will (if applicable):
Date(s) of Codicil(s) (if applicable):

 

 

Date of probate (if different from date Letters granted):

Was a bond required? [_]Yes [[]No If yes, state amount:
Are proofs of advertising of the grant of Letters attached? ...([] Yes [[] No
Dates of advertising of the grant of Letters:

Form OC-01 rev. 01.01.20 Page 2 of 11
Estate of , Deceased

3. Was decedent survived by a spouse? ...................005. L]Yes [No

If yes, name of the surviving spouse:

 

4. Has the surviving spouse filed to take an elective share? . .[_] Yes[_] No LINyvA
(see 20 Pa.C.S. §§ 2201 et seq.)

If yes, attach a copy of the election and state date of election:

5. In the case of an intestacy, state the names of the decedent's surviving children or
surviving issue of deceased children (if none, so state):

6. Did decedent marry after execution of Will or Codicil(s)? ........ []Yes[-]No [_] N/A

Were any children born to decedent after execution of
Will or Codicil(s)? 22.0.0... cece eee []Yes_JNo(] N/A

If yes, give names and dates of birth:

Name: Date of Birth:

 

 

 

 

7. Was a request for a statement of claim, as required by the Medical Assistance
Estate Recovery Act, 62 P.S. § 1412, sent to the Department of
Human Services? ........00.0 0.00 cece eee eee eee CJ Yes (] Nol] N/A

Form OC-01 rev. 01.01.20 Page 3 of 11
Estate of , Deceased

8. Written notice of the Account's filing as required by Pa. O.C. Rule 2.5 has been or will be
given to all interested parties listed in item 9 below, all unpaid creditors and all claimants
listed in item 10 below. In addition, notice of any questions requiring adjudication as
discussed in item 15 below has been or will be given to all persons affected thereby. If one
of the beneficiaries is a trust or another estate and any of the accountants is also a
fiduciary of the receiving trust or estate, provide written notice of the Accounts filing to the
beneficiaries of the trust or receiving estate, as applicable, if known.

A. If Notice has been given, attach a copy of the Notice as well as a list of the names
and addresses of the parties receiving such Notice.

B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and
addresses of the parties receiving such Notice shall be submitted at the Audit or filed
before the date of the last day for filing objections in counties without separate
Orphans’ Court Divisions together with a statement executed by a Petitioner or
counsel certifying that such Notice has been given.

C. If any such interested person is not sui juris (e.g., minors or incapacitated persons),
Notice has been or will be given to the appropriate representative on such party's
behalf as required by Pa. O.C. Rule 4.2.

D. If any charitable interest is involved, Notice has been or will also be given to the
Attorney General as required under Pa. O.C. Rule 4.4. In addition, the Attorney
General's clearance certificate (or proof of service of Notice and a copy of such
Notice) must be submitted herewith or at the Audit or filed before the date of the last
day for filing objections in counties without separate Orphans’ Court Divisions.

9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or
knowledge, having or claiming any interest in the estate as beneficiaries under the Will (if
beneficiary is a trust, name the trust and trustee as the Interested Party) or Codicil(s) or as
interstate heirs if there is a complete or partial intestacy. This list Shall:

A. State each party's relationship to the decedent and the nature of each party's
interest(s):

Name and Address of Each interested Party | Relationship and Comments, if any interest

 

 

 

 

 

Form OC-01 rev. 01.01.20 Page 4 of 11
Estate of

Name and Address of Each interested Party

Relationship and Comments, if any

, Deceased

interest

 

 

 

 

 

B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth, the name of each Guardian and
how each Guardian was appointed. If no Guardian has been appointed,
identify the next of kin of such party, giving the name, address,

and relationship of each.

C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed

(see Pa. O.C. Rule 5.5).

Form OC-01 rev. 01.01.20

Page 5 of 11
Estate of

D. If distribution is to be made to the personal representative of a deceased

, Deceased

party, state date of death, date and place of grant of Letters and type of

Letters granted.

10. Other than the claim for the family exemption, list the names of all known claimants and
the amount of their claims and state whether each claim is admitted.

 

 

 

 

Name and Address of Each Claimant Amount of Claim Claim Will Claim
Admitted? Be Paid In
Full?

[_]Yes [-]Yes
[[]No L_JNo

[ Nes [_]Yes
[_]No [_]No

[Yes []Yes
[_]No [-]No

[Yes [Yes
[] No [_]No

 

 

 

 

if the estate is insolvent, attach a schedule setting forth the order of
preference under 20 Pa.C.S. § 3392 and the proposed payments.

Form OC-01 rev. 01.01.20

Page 6 of 11
Estate of , Deceased

11. Was family exemption claimed? oo... .ceccccceceseeecsetsseeesereneseees [Wes [No

Was family exemption allowed? .................cceeccescesessessenstenneeeees []Yes [JNo
Family exemption claimant's name and relationship:

Name: Relationship:

12. The amount of Pennsylvania Transfer Inheritance Tax paid, the date(s) of payment(s), and
the interest(s) upon which paid, are as follows:

Date Payment lnterest

 

 

 

13. On the date of death, was the decedent a fiduciary
(personal representative, trustee, guardian, agent under power
of attorney) or surety on the bond ofa fiduciary? .............. [Yes L]No

If yes, provide the name of the estate, indicate whether an Account has been
filed and confirmed and all awards performed, or, in the alternative,
how the decedent's estate will be discharged for the decedent's fiduciary
administration of the estate.

Form OC-01 rev. 01.01.20 Page 7 of 11
Estate of , Deceased

 

14. On the date of death, was the decedent a party (as a
plaintiff or defendant) in any litigation? .................0..00.. [-]Yes [No
If yes, provide the caption of the litigation, docket number, where the
matter is currently pending, and its status.

15. A. Describe in detail any questions requiring adjudication and state the position of the
Petitioner(s) as to each question:

B. Has notice of the question requiring adjudication been given
to the parties identified in Paragraph 9 above? .......... [Yes []No

16. If Petitioner(s) has/have knowledge that a share has been assigned, renounced,

disclaimed, or attached, provide a copy of the assignment, renunciation, disclaimer, or
attachment, together with any relevant supporting documentation and list the attached

documents below.

Form OC-01 rev. 01.01.20 Page 8 of 11
Estate of , Deceased

17. Had the decedent been adjudicated an incapacitated person? [Yes []|No

If yes, attach a copy of the Order if available; otherwise state the Court,
docket number, date, and name of Hearing Judge.

18. A. List or attach a separate list of additional receipts and disbursements since the closing
date of the Account.

B. Has notice of the additional receipts and disbursements been
given to the parties identified in Paragraph 9 above? ..... [.] Yes [] No

19. If areserve is requested, state amount and purpose.
Amount:

Purpose:

If a reserve is requested for counsel fees, has notice of the
amount of fees to be paid from the reserve been given to the

interested parties ? 2.02... ce []Yes [No
Ifso, attach a copy of the notice.

Form OC-01 rev. 01.01.20 Page 9 of 11
Estate of , Deceased

20. ‘If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the
Court being asked to direct the filing of a Schedule of Distribution?. ..[]Yes [No

As to real estate only?

Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties
entitled and suggest(s) that the distributive shares of income and principal (residuary
shares being stated in proportions, not amounts) are as follows:

 

 

 

 

A. Income:

Proposed Distributee(s) Amount/Proportion
B. Principal:

Proposed Distributee(s) Amount/Proportion

 

 

 

 

Submitted By:
(All petitioners must sign. Place additional
signatures on attachment if necessary):

Corporate Fiduciary (if applicable)

 

 

 

Name of Corporate Fiduciary Name of Petitioner
Name of Representative and Title Signature of Petitioner
Signature of Officer/Representative Name of Petitioner

 

Signature of Petitioner

Form OC-01 rev. 01.01.20 Page 10 of 11
Estate of , Deceased
(Verification must be by at least one petitioner.)

Verification for Individual Petitioner

The undersigned hereby verifies that the averment of facts set forth in the foregoing
Petition for Adjudication/Statement of Proposed Distribution which are within the
personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be
true; and that any false statements herein are made subject to the penalties of
18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

Date Signature of Petitioner

Verification for Corporate Petitioner

The undersigned hereby verifies that he/she iS title of the
above-named name of corporation and
that the averment of facts set forth in the foregoing Petition for Adjudication/
Statement of Proposed Distribution which are within the personal knowledge of the
Petitioner are true, and as to facts based on the information of others, the Petitioner,
after diligent inquiry, believes them to be true; and that any false statements herein
are made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn
falsification to authorities).

 

 

 

 

 

Date Signature of Representative for Corporate Petitioner

Certification of Counsel
The undersigned counsel hereby certifies that the foregoing Petition for
Adjudication/ Statement of Proposed Distribution is a true and accurate
reproduction of the form Petition authorized by the Supreme Court, and that no
changes to the form have been made beyond the responses herein.

 

 

Date Signature of Counsel for Petitioner

Form OC-01 rev. 01.01.20 Page 11 of 11
TRUST
COURT OF COMMON PLEAS OF

ORPHANS’ COURT DIVISION

NAME OF TRUST
(TRUST UNDER WILL OF

or
TRUST UNDER DEED OF

DATED ——_____________)
No.

 

PETITION FOR ADJUDICATION /
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. 0.C. Rule 2.4

This form shall be used in all cases involving the Audit or Confirmation of Trust Accounts.
If space ts insufficient, riders may be attached. Attach the papers required under items 2,
4, 15-19, as applicable, and any instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

Name of Counsel:
Supreme Court |.D. No.:

 

 

Name of Law Firm:

 

Address:

 

 

Telephone:
Fax:
Email:

 

 

 

Form OC-02 rev.01.01.20 Page 1 of 11
Name of Trust:

 

1. Name(s) and address(es) of Petitioner(s):
Petitioner: Petitioner:

Name:

 

Address:

 

 

Identify any Trustees who have not joined in the Petition for Adjudication/Statement
of Proposed Distribution and/or the Account and state reason:

2. Pursuant to 20 Pa.C.S. § 7799.1, if property from a personal representative or a trustee
of another trust is being received by this Trust, an Account of the administration of such
estate or trust may be annexed to the Trust Account. Is any such Account annexed to this
Trust Account? ... 0.0... ccc cece ee tee ene eee eens [| Yes [ | No

If so, the annexed Account and the appropriate fully completed Petition for Adjudication/
Statement of Proposed Distribution for the annexed matter should be filed as Exhibits to
this Petition.

3. Check if any of the following issues are involved in this case:

A. Appointment of Trustee... 0... ec ee eee nee C
B. Interpretation... 0.0.0... eee eee eee eee nenes [|
C. Discharge of Trustee............ beeen eee e eee eee e teen teen eneneners []
D. Transfer of Situs 0.0... ccc cee cece ence tee eevee eeeeetanes []
E. Appointment of Ad Lifem.... 0.0.00. 00000000 ccc cece ee []
F. Minor, Unborn or Unascertained Beneficiary(ies)................... CJ
G. Principal Distribution... 0... cece eee ene ee eenas J
H. Partial/Full Termination of Trust...........0.0 00.0 cece eee ee eee [|
|. Missing Beneficiary(ies) ..........0 000000 e cece cece erence ee eneenees [|
Jo CY PLES 2 oc cc nee eee ene n eens C]
K. Other Issues... 20.0... ee ee ene nen e nee [|
List:

Form OC-02 rev. 01.01.20 Page 2 of 11
Name of Trust:

 

Please note:
A detailed explanation of issues checked should be set forth at item 14 below.

4. Testamentary Trust:

Decedents' date of death:
Date of Decedents' Wilk:

Date(s) of Codicil(s):
Date of probate:

 

 

 

 

Judicial District or County where Letters were
issued: or

inter Vivos Trust:

Date of Trust:

 

Date(s) of Amendment(s):

 

lf Settlor is deceased and letters were not issued or the personal
representative did not advertise the estate, state dates when the Trustee
advertised Settlor’s death and attach proofs of advertising:

Is this inter vivos trust a Special Needs Trust established under
42 U.S.C. § 1396p(d)(4)? 2.0 cece ee eee [ ]Yes []No

5, Explain why venue is proper before this Court (see 20 Pa.C.S. § 7714}, and why the Trust's
situs is located in this judicial district or county (see 20 Pa.C.S. § 7708).

6. A. If any other Court has taken jurisdiction of any matter relating to this Trust, explain:

B. Is this the first accounting of this Trust? ................... []Yes []No

Form OC-02 rev.01.01.20 Page 3 of 11
Name of Trust:

 

C. If not, identify prior accountings, the accounting periods covered, and the dates of
adjudication of the prior accountings.

7. A. State how each Trustee was appointed:

B If a Petitioner is not a Trustee (e.g., executor or administrator of deceased trustee,
agent, or guardian of an incapacitated trustee), explain:

8. State how and when the present fund was awarded to Trustee(s):

9. Period covered by this Account: to

 

10.Current fair market value of the Trust principal is $
(see page of Account.)

 

11. State concisely the dispositive provisions of the Trust:

Form OC-02 rev. 01.01.20 Page 4 of 11
Name of Trust:

 

12. Explain the reason for filing this Account (if filed because of the death of a party, state
name of person, relationship to Trust, and date of death):

13. A. State the amount of Pennsylvania Transfer Inheritance Tax paid (including postponed
tax on remainder interests), the dates of payment and the interests upon
which such amounts were paid:

Date Payment Interest

 

 

 

 

B. If any such taxes remain unpaid or are in dispute, explain:

14. Describe any questions requiring adjudication, state the position of Petitioner(s) as
to each question, and give details of any issues identified in item 3:

15. Written notice of the Account's filing as required by Pa. O.C. Rule 2.5 has been or
will be given to all interested parties listed in item 16 below. If any person is
being asked to represent the interests of another interested party (whether su/
juris or not), the person asked to serve as a representative has been so
notified and given an opportunity to decline pursuant to 20 Pa.C.S. § 7725.
In addition, notice of any questions requiring adjudication as discussed in item
14 above has been or will be given to all persons affected thereby. If one of the
beneficiaries is a trust or estate and any of the accountants is also a fiduciary of
the receiving trust or estate, provide written notice of the Account's filing to the
beneficiaries of the receiving trust or estate, as applicable, if known.

Form OC-02 rev. 01.01.20 Page 5 of 11
Name of Trust:

 

A. If Notice has been given, attach a copy of the Notice as well as a list of the
names and addresses of the parties receiving such notice. Unless contained
in the attached Notice, attach a copy of the written notice provided to any
person who is being asked to represent another or attach such person's
consent to serve.

B. If Notice is yet to be given, a copy of the Notice as well as a list of the names
and addresses of the parties receiving such Notice shall be submitted at the
Audit or filed before the date of the last day for filing objections in counties
without separate Orphans’ Court Divisions together with a statement executed
by Petitioner(s) or counsel certifying that such Notice has been given. Unless
contained in the Notice or previously attached, a copy of the written notice
provided to any person who is being asked to represent another or such
person's consent to serve shall be submitted at the Audit or filed before the
date of the last day for filing objections in counties without separate Orphans'
Court Divisions.

C. If any such interested party is not sui juris (e.g., minors or incapacitated
persons), Notice has been or will be given to the appropriate representative on
such party's behalf as required by Pa. O.C. Rule 4.2.

D. If any charitable interest is involved, Notice has been or will also be given to
the Attorney General as required under Pa. O.C. Rule 4.4. In addition, the
Attorney General's clearance certificate (or proof of service of Notice and a
copy of such Notice) must be submitted herewith or at the Audit or filed before
the date of the last day for filing objections in counties without separate
Orphans’ Court Divisions.

E. If the Account before the Court is a Special Needs Trust established under 42
U.S.C. § 1396p(d)(4), Notice has been or will also be given to the
Pennsylvania Department of Human Services, Special Needs Trust Depository
and to the applicable department of any other state that has provided the
special needs beneficiary with medical care under a state medical assistance
program ("Department"). In addition, the Department's letter of no objection
(or proof of service of Notice and a copy of such Notice) must be submitted
herewith or at the Audit or filed before the date of the last day for filing
objections in counties without separate Orphans' Court Divisions.

16. List all parties of whom Petitioner(s) has/have notice or knowledge, having or claiming
any interest in the Trust (if beneficiary is a trust, name the trust and trustee as the
Interested Party), whether such interest is vested or contingent, charitable or non-
charitable. This list shall:

A. State each party’s relationship to the Settlor/Decedent and the nature of each

party’s interest(s);
Name and Address of Each Interested Party | Relationship and Comments, if any interest

 

 

 

 

 

 

 

Form OC-02 rev.01.01.20 Page 6 of 11
Name of Trust:

 

 

Nae and Address of Each interested Party {Relationship and Comments if Any interest

 

 

 

B. If any interested party (whether sui juris or not) is not receiving Notice of
the filing of the Account and the Petition for Adjudication/Statement of
Proposed Distribution because another individual is proposed to
represent such interested party pursuant to 20 Pa.C.S. §§ 7721-7726,
provide the information below for each proposed representative. If there is
more than one proposed representative, attach a rider setting forth the
information below for each additional proposed representative:

(i) Name of Proposed Representative:
Describe Proposed Representative's Interest(s) in Trust:

 

Name of the interested parties or description of the class of interested
parties whom the person named above is to represent and describe such
persons' interest in Trust:

(ii) Has any person who is proposed to be represented as identified
in the question above notified a Trustee in writing that he or
she objects to such representation? ................. [| Yes | No

If yes, provide Name(s) of Person(s) objecting to being represented:

(ili) Specify the subparagraph(s) under 20 Pa. C.S. § 7723 authorizing representation:

 

(iv) Is there any conflict of interest? .................... [ ]Yes []No
If yes, explain conflict and why representation should be permitted:

Form OC-02 rev. 01.01.20 Page 7 of 11
 

Name of Trust:

(v) Has Proposed Representative provided written consent? C]yYes [| No
If no, has Proposed Representative declined in writing to
act in the representative capacity as requested? ...... [Yes [] No

if Proposed Representative has neither consented to act in writing nor
declined in writing to act, provide date of the letter in which Proposed
Representative was notified that he or she is to represent another
person or class of interested parties:

 

C. Identify each party who is not sui juris (e.g., minors or incapacitated persons).

For each such party, give date of birth, the name of each Guardian, and
how each Guardian was appointed. If no Guardian has been appointed,
identify the next of kin of such party, giving the name, address, and
relationship of.each.

D. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed
(see Pa. O.C. Rule 5.5).

E. If distribution is to be made to the personal representative of a deceased party,
state date of death, date and place of grant of Letters, and type of Letters granted.

Form OC-02 rev. 01.01.20 Page 8 of 11
 

Name of Trust:

17. If Petitioner(s) has/have knowledge that a Trust share has been assigned,
renounced, disclaimed, or attached, provide a copy of the assignment,
renunciation, disclaimer, or attachment, together with any relevant
supporting documentation and list the attached documents below.

18. If a Trustee’s principal commission is claimed:

A. If based on a written agreement, attach a copy thereof.

 

B. Ifa principal commission is claimed, state amount.$

C. If a principal commission is claimed, state the amounts and dates of any
principal commissions previously paid in prior accounting periods.

 

 

 

 

19. if a reserve is requested, state amount and purpose.

Amount: .

 

Purpose:

 

 

 

If a reserve is requested for counsel fees, has notice of the
amount of fees to be paid from the reserve been given to the
interested parties? .. 0.0.0... ce ee eens []Yes [_]No

If so, attach a copy of the notice.

20. If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the
Court being asked to direct the filing of a Schedule of Distribution? L ]Yes [_]No

Form OC-02 rev. 01.01.20 Page 9 of 11
Name of Trust:

 

Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties
entitled and suggest(s) that the distributive shares of income and principal (residuary
shares being stated in proportions, not amounts) are as follows:

 

 

 

A. Income:

Proposed Distributee(s) Amount/Proportion
B. Principal:

Proposed Distributee(s) Amount/Proportion

 

 

 

Submitted By:
(All petitioners must sign. Place additional
signatures on attachment if necessary):

Corporate Fiduciary (if applicable)

 

 

 

Name of Corporate Fiduciary Name of Petitioner
Name of Representative and Title Signature of Petitioner
Signature of Officer/Representative Name of Petitioner

 

Signature of Petitioner

Form OC-02 rev. 01.01.20 Page 10 of 11
Name of Trust:

 

(Verification must be by at least one petitioner.)
Verification for Individual Petitioner

The undersigned hereby verifies that the averment of facts set forth in the foregoing
Petition for Adjudication/Statement of Proposed Distribution which are within the
personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be
true; and that any false statements herein are made subject to the penalties of
18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

Date Signature of Petitioner

Verification for Corporate Petitioner

The undersigned hereby verifies that ne/sne is
title of the above-named name of comoration
and that the averment of
facts set forth in the foregoing Petition for Adjudication/Statement of Proposed
Distribution which are within the personal knowledge of the Petitioner are true, and
as to facts based on the information of others, the Petitioner, after diligent inquiry,
believes them to be true; and that any false statements herein are made subject to
the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

 

Date Signature of Representative for Corporate
Petitioner

Certification of Counsel

The undersigned counsel hereby certifies that the foregoing Petition for
Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction
of the form Petition authorized by the Supreme Court, and that no changes to the
form have been made beyond the responses herein.

 

 

Date Signature of Counsel for Petitioner

Form OC-02 rev. 01.01.20 Page 11 of 11
GUARDIANSHIP OF INCAPACITATED PERSON

COURT OF COMMON PLEAS OF

ORPHANS' COURT DIVISION

ESTATE OF , AN INCAPACITATED PERSON ,
ACCOUNT OF GUARDIAN
No.

PETITION FOR ADJUDICATION /
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. O.C. Rule 2.4

This form shall be used in all cases involving the Audit or Confirmation of the Account of a
Guardian of the Estate of an incapacitated person. If space is insufficient, riders may be
attached. Attach the papers required under items 2, 3, and 5, as applicable, and any
additional decree or instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

Name of Counsel:

 

Supreme Court |.D. No.:

 

Name of Law Firm:

 

Address:

 

 

Telephone:

 

Fax:

 

Email:

 

Form OC-03 rev. 01.01.20 Page 1 of 6
Estate of , An Incapacitated Person

1. Name(s) and address(es) of Petitioner(s):

Petitioner: Petitioner:
Name:

 

Address:

 

 

identify any Guardians of the Estate who have not joined in the Petition for
Adjudication/Statement of Proposed Distribution and/or the Account and state
reason:

2. Judicial District or County issuing Adjudication of Incapacity:

 

Date of Adjudication of Incapacity:
Date of Appointment as Guardian:
Attach copy of Decree(s).

3. A. Explain the reason for filing this Account (if incapacitated person has died, state date
of death, name and address of personal representative and of his or her counsel, and
attach a Short Certificate if available. If incapacitated person has been adjudged to
have regained capacity, state date of Decree and attach a copy. If Account is filed for
any other reason, state address of incapacitated person):

B. Is this the first accounting for this estate? ................. [ ]Yes[_]No
if not, identify prior accountings, the accounting periods covered, and the
dates of adjudication of the prior accountings.

4. A. Identify each unpaid claim against the incapacitated person or the incapacitated
person's estate and describe each in detail (if none, so state):

Form OC-03 rev. 01.01.20 Page 2 of 6
Estate of , An incapacitated Person

B. Describe in detail any questions requiring adjudication and state the position of the
Petitioner(s) as to each question:

C. If guardian or attorney fees are being claimed, state amount and the period covered
for the requested fees:

5. Written Notice of the Accounts filing as required by Pa. O.C. Rule 2.5 has been
or will be given to all interested parties listed in item 6 below. In addition, notice of
any known unpaid claim not admitted, all questions requiring adjudication and any
requested fees as discussed in item 4 above has been or will be given to all
persons affected thereby.

A. If Notice has been given, attach a copy of the Notice as well as a list of the
names and addresses of the parties receiving such Notice.

B. If Notice is yet to be given, a copy of the Notice as well as a list of the
names and addresses of the parties receiving such Notice shall be
submitted at the Audit or filed before the date of the last day for filing
objections in counties without separate Orphans' Court Divisions together
with a statement executed by a Petitioner or counsel certifying that such
Notice has been given.

C. If any such interested party is not sui juris (e.g., minors or incapacitated
persons), Notice of the Accounts filing has been or will be given to the

appropriate representative on such party’s behalf as required by Pa. O.C.
Rule 4.2.

Form OC-03 rev. 01.01.20 Page 3 of 6
Estate of , An Incapacitated Person

6. List all parties of whom Petitioner(s) has/have notice or knowledge, having or
claiming any interest in the estate, including the incapacitated person's heirs at
law. This list shall:
A. State each party’s relationship to the incapacitated person and the nature of each
party's interest(s):

Name and Address of Each interested Party |Relationship and Commenis, if any} interest

 

 

 

 

 

 

 

 

B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth, the name of each Guardian, and
how each Guardian was appointed. If no Guardian has been appointed,
identify the next of kin of such party, giving the name, address, and
relationship of each.

C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed
(see Pa. O.C. Rule 5.5).

7. If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the
Court being asked to direct the filing of a Schedule of Distribution? [_]Yes [_]No

Form OC-03 rev. 01.01.20 Page 4 of 6
Estate of

, An Incapacitated Person

 

Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties
entitled and suggest(s) that the distributive shares of income and principal (residuary
shares being stated in proportions, not amounts) are as follows:

 

 

A. Income:

Proposed Distributee(s) Amount/Proportion
B. Principal:

Proposed Distributee{s) Amount/Proportion

 

 

Corporate Fiduciary (if applicable)

Submitted By:

(All petitioners must sign. Place
additional signatures on attachment if
necessary):

 

Name of Corporate Fiduciary

Name of Petitioner

 

Name of Representative and Title

Signature of Petitioner

 

Signature of Officer/Representative

Form OC-03 rev. 01.01.20

Name of Petitioner

 

Signature of Petitioner

Page 5 of 6
Estate of , An Incapacitated Person
(Verification must be by at least one petitioner.)

Verification for Individual Petitioner

The undersigned hereby verifies that the averment of facts set forth in the foregoing
Petition for Adjudication/Statement of Proposed Distribution which are within the
personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be
true; and that any false statements herein are made subject to the penalties of
18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

Date Signature of Petitioner

Verification for Corporate Petitioner

The undersigned hereby verifies that he/she is

title of the above-named name of corporation
and that the averment of
facts set forth in the foregoing Petition for Adjudication/Statement of Proposed
Distribution which are within the personal knowledge of the Petitioner are true, and
as to facts based on the information of others, the Petitioner, after diligent inquiry,
believes them to be true; and that any false statements herein are made subject to
the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

 

Date Signature of Representative for
Corporate Petitioner

Certification of Counsel

The undersigned counsel hereby certifies that the foregoing Petition for
Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of
the form Petition authorized by the Supreme Court, and that no changes to the form have
been made beyond the responses herein.

 

 

Date Signature of Counsel for Petitioner

Form OC-03 rev. 01.01.20 Page 6 of 6
GUARDIANSHIP OF MINOR

COURT OF COMMON PLEAS OF

ORPHANS’ COURT DIVISION
ESTATE OF , AMINOR
ACCOUNT OF , GUARDIAN

No.

PETITION FOR ADJUDICATION /
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. O.C. Rule 2.4

This form shall be used in all cases involving the Audit or Confirmation of the
Account of a Guardian of the Estate of a minor or late minor. If space is insufficient,
riders may be attached. Attach the papers required under items 2 and 5, as applicable,
and any instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

Name of Counsel:

 

Supreme Court |.D. No.:

 

Name of Law Firm:

 

Address:

 

 

Telephone:

 

Fax:

 

Email:

 

Form OC-04 rev. 01-01-20 Page 1 of 6
Estate of _ A Minor

1.

3.

4.

Name(s) and address(es) of Petitioner(s):

Petitioner: Petitioner:
Name:

 

Address:

 

 

identify any Guardian of the Estate who has not joined in the Petition for
Adjudication/Statement of Proposed Distribution and/or the Account and state
reason:

Judicial District or County Appointing Guardian:

 

Date of Appointment as Guardian:
Attach copy of Decree(s).

 

A. Explain the reason for filing this Account (if minor has come of age, state date minor
attained majority).

B. Is this the first accounting for this estate?................ [ | Yes [| No

If not, identify prior accountings, the accounting periods covered, and the
dates of adjudication of the prior accountings.

A. Identify each unpaid claim against the minor or the minor's estate and describe in
detail (if none, so state):

Form OC-04 rev. 01-01-20 Page 2 of 6
Estate of , A Minor

B. Describe in detail any questions requiring adjudication and state the position of the
Petitioner(s) as to each question:

C. If guardian or attorney fees are being claimed, state amount and the period covered
for the requested fees:

5. Written Notice of the Account's filing as required by Pa. O.C. Rule 2.5 has been or
will be given to all interested parties listed in item 6 below. In addition, notice of any
unpaid claim not admitted, all questions requiring adjudication, and any requested
fees as discussed in item 4 above has been or will be given to all persons affected
thereby.

A. If Notice has been given, attach a copy of the Notice as well as a list of the
names and addresses of the parties receiving such Notice.

B. If Notice is yet to be given, a copy of the Notice as well as a list of the
names and addresses of the parties receiving such Notice shall be
submitted at the Audit or filed before the date of the last day for filing
objections in counties without separate Orphans’ Court Divisions together
with a statement executed by a Petitioner or counsel certifying that such
Notice has been given.

C. If any such interested party is not sui juris (e.g., minors or incapacitated
persons), Notice of the Account's filing has been or will be given to the
appropriate representative on such party's behalf as required by Pa. O.C.
Rule 4.2.

Form OC-04 rev. 01.01.20 Page 3 of 6
Estate of ,AMinor

6. List all parties of whom Petitioner(s) has/have notice or knowledge, having or
claiming any interest in the estate, including the minor's heirs at law. This list

shall:
A. State each party's relationship to the minor and the nature of each party's
interest(s):
Name and Address of Each interested Party | Relationship and Comments, if any interest

 

 

 

 

 

 

 

 

B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth, the name of each Guardian, and how
each Guardian was appointed. If no Guardian has been appointed, identify the
next of kin of such party, giving the name, address, and relationship of each.

C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed -
(see Pa. O.C. Rule 5.5).

7. — If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the
Court being asked to direct the filing of a Schedule of Distribution? [_] Yes []No

Form OC-04 rev. 01.01.20 Page 4 of 6
Estate of ,AMinor

Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties
entitled and suggest(s) that the distributive shares of income and principal (residuary
shares being stated in proportions, not amounts) are as follows:

 

 

A. Income:

Proposed Distributee(s) Amount/Proportion
B. Principal:

Proposed Distributee(s) Amount/Proportion

 

 

Submitted By:
(All petitioners must sign. Place additional
signatures on attachment if necessary):

Corporate Fiduciary (if applicable)

 

 

 

Name of Corporate Fiduciary Name of Petitioner
Name of Representative and Title Signature of Petitioner
Signature of Officer/Representative Name of Petitioner

 

Signature of Petitioner

Form OC-04 rev. 01.01.20 Page 5 of 6
Estate of _ A Minor

(Verification must be by at least one petitioner.)

Verification for individual Petitioner

The undersigned hereby verifies that the averment of facts set forth in the foregoing
Petition for Adjudication/Statement of Proposed Distribution which are within the
personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be
true; and that any false statements herein are made subject to the penalties of
18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

Date Signature of Petitioner

Verification for Corporate Petitioner

 

 

The undersigned hereby verifies that he/she iS title
of the above-named name of
corporation and that the

 

averment of facts set forth in the foregoing Petition for Adjudication/Statement of
Proposed Distribution which are within the personal knowledge of the Petitioner are
true, and as to facts based on the information of others, the Petitioner, after diligent
inquiry, believes them to be true; and that any false statements herein are made
subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to
authorities).

 

 

Date Signature of Representative for Corporate
Petitioner

Certification of Counsel

The undersigned counsel hereby certifies that the foregoing Petition for
Adjudication/ Statement of Proposed Distribution is a true and accurate
reproduction of the form Petition authorized by the Supreme Court, and that no
changes to the form have been made beyond the responses herein.

 

 

Date Signature of Counsel for Petitioner

Form OC-04 rev. 01.01.20 Page 6 of 6
PRINCIPAL’S ESTATE
(Under Power of Attorney)

COURT OF COMMON PLEAS OF

ORPHANS’ COURT DIVISION

ESTATE OF , PRINCIPAL ,
ACCOUNT OF AGENT(S) *
No.

PETITION FOR ADJUDICATION /
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. O.C. Rule 2.4

This form shall be used in all cases involving the Audit or Confirmation of the Account
of one or more Agents acting under a Power of Attorney. lf space
is insufficient, riders may be attached. Attach the papers required under items 3, 4,
and 9, as applicable, and any instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

Name of Counsel:

 

Supreme Court 1.D. No.:

 

Name of Law Firm:
Address:

 

 

 

 

Telephone:

Fax:

 

Email:

 

* The term “Agent” shail include any person designated as an “attorney-in-fact” or acting in a similar capacity by the Principal's
delegation.

Form OC-05 rev. 01.01.20 Page 1 of 8
Estate of , Principal

 

1. Name(s) and address(es) of Petitioner(s):
Petitioner: Petitioner:

Name:

 

Address:

 

 

 

Name(s) and address(es) of Agent(s) (if not Petitioner(s)):
Agent: Agent:

Name:

 

Address:

 

 

Identify any Agents who have not joined in the Petition for Adjudication/
Statement of Proposed Distribution and/or the Account and state reason:

2. Name and address of Principal (and, if applicable, of any Guardian appointed for Principal,
of each personal representative for any Principal or Agent who has died, and of
his or her counsel, identifying the capacity of each):

Judicial District or County where Principal resides, or if Principal is deceased, where
Letters were issued:

3. A. Date of Principal's Power of Attorney under which Agent(s) acted:

 

B. Date Agent(s) first exercised control of Principal's assets under Power of Attorney:

(Attach copy of each different Power of Attorney granted to Agent(s) by Principal and copy of any
Decree involving Agent(s) for Principal).

Form OC-05 rev. 01.01.20 Page 2 of 8
Estate of , Principal

 

4. A. Explain the reason for filing this Account (if Principal or Agent has died, state date of
death, and attach a Short Certificate; if Principal has been
incapacitated, state date of Decree, and attach a copy):

B. Is this the first accounting for this Principal's estate? ...[_ Yes []No

If not, identify prior accountings, the accounting periods covered,
and the dates of adjudication of the prior accountings.

5. Describe all gifts/transfers for less than full and adequate consideration made under the
Power of Attorney. Identify each recipient’s name, address, and relationship to
Principal and/or Agent, amount of each gift/transfer, nature of each (cash or
kind), and date made, with any additional explanation deemed appropriate (if

none, so state):

6. Identify every asset or interest (include title or registration and value) of Principal known
to Petitioner(s) and not identified in Account, whether or not in possession or
control of Petitioner(s) (if none known, so state):

Form OC-05 rev. 01.01.20 Page 3 of 8
Estate of , Principal

7. Identify each existing safe deposit box of or for Principal and each one closed by Agent(s)
(if not applicable, so state):

Institution & Address Box No. Title or Registration Date Closed (if applicable)

 

 

 

 

 

 

 

 

Are the entire contents of each safe deposit box identified in item 7
above included in the filed Account? ................. 020000 [ ]Yes []No

If not, explain:

8. A. Identify each known unpaid claim against Principal or Principal's estate and describe
each in detail (if none, so state):

B. Describe in detail any questions requiring adjudication and state the position of the
Petitioner(s) as to each question:

Form OC-05 rev. 01.01.20 Page 4 of 8
Estate of , Principal

C. If fees are being claimed by the Agent or an attorney, state amount and the period
covered for the requested fees:

9. Written Notice of the Account's filing as required by Pa. O.C. Rule 2.5 has been or
will be given to each interested party in the matter. In addition, notice of any unpaid
claim not admitted, all questions requiring adjudication, and any requested fees as
described in item 8 above has been or will be given to-all parties affected thereby.

A. If Notice has been given, attach a copy of the Notice as well as a list of the
names and addresses of the parties receiving such Notice.

B. If Notice is yet to be given, a copy of the Notice as well as a list of the names
and addresses of the parties receiving such Notice shall be submitted at the
Audit or filed before the date of the last day for filing objections in counties
without separate Orphans' Court Divisions together with a statement executed
by a Petitioner or counsel certifying that such Notice has been given.

C. If any such interested party is not sui juris (e.g., minors or incapacitated
persons), Notice of the Account's filing has been or will be given to the
appropriate representative on such party's behalf as required by Pa. O.C. Rule
4.2.

10. _ List all parties of whom Petitioner(s) has/have notice or knowledge, having or claiming
any interest in the Principal's estate. This list shall:

A. State each party’s relationship to the Principal and the nature of each party's
interest(s):

Name and Address of Each Interested Party | Relationship & Comments, if any Interest

 

 

 

 

 

 

 

 

Form OC-05 rev. 01.07.20 Page 5 of 8
Estate of , Principal

 

B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth, the name of each Guardian,
and how each Guardian was appointed. If no Guardian has been
appointed, identify the next of kin of such party, giving the name,
address, and relationship of each.

C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed
(see Pa. O.C. Rule 5.5).

11. If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the
Court being asked to direct the filing of a Schedule of Distribution? C Yes LJNo

Form OC-05 rev. 01.01.20 Page 6 of 8
Estate of , Principal

Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties
entitled and suggest(s) that the distributive shares of income and principal (residuary
shares being stated in proportions, not amounts) are as follows:

 

 

A. Income:

Proposed Distributee(s) Amount/Proportion
B. Principal:

Proposed Distributee(s) Amount/Proportion

 

 

Submitted By:
(All petitioners must sign. Place additional
signatures on attachment if necessary):

Corporate Fiduciary (if applicable)

 

 

 

Name of Corporate Fiduciary Name of Petitioner
Name of Representative and Title Signature of Petitioner
Signature of Officer/Representative Name of Petitioner

 

Signature of Petitioner

Form OC-05 rev. 01.01.20 Page 7 of 8
Estate of , Principal
(Verification must be by at least one petitioner.)

Verification for Individual Petitioner

The undersigned hereby verifies that the averment of facts set forth in the foregoing
Petition for Adjudication/Statement of Proposed Distribution which are within the
personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be
true; and that any false statements herein are made subject to the penalties
of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

 

 

Date Signature of Petitioner

Verification for Corporate Petitioner

 

 

The undersigned hereby verifies that he/she is
tille of the above-named
name of corporation and that

 

the averment of facts set forth in the foregoing Petition for Adjudication/Statement of
Proposed Distribution which are within the personal knowledge of the Petitioner are
true, and as to facts based on the information of others, the Petitioner, after
diligent inquiry, believes them to be true; and that any false statements herein are
made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification
to authorities).

 

 

Date Signature of Representative for
Corporate Petitioner

Certification of Counsel

The undersigned counsel hereby certifies that the foregoing Petition for
Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of
the form Petition authorized by the Supreme Court, and that no changes to the form
have been made beyond the responses herein.

 

 

Date Signature of Counsel for Petitioner

Form OC-05 rev. 07.01.20 Page 8 of 8
OATH OF SUBSCRIBING WITNESS(ES)
REGISTER OF WILLS

Estate of , Deceased

 

, (each) a subscribing witness to
(Print Name/s)

the [_]will [-] Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s)
and say(s) that she/he/they was/were  presentand sawthe above _ Testator/ Testatrix
sign the same andthat she/he/they signed the same and that she/he/they signed as
a witness at the request of the Testator / Testatrix in her/his presence and in the presence
of each other.

 

 

 

 

 

 

(Signature) (Signature)
(Street Address) (Street Address)
(City, State, Zip) (City, State, Zip)

Executed in Register’s Office Executed out of Register’s Office

 

 

 

 

Commonwealth of Pennsylvania )
Sworn to or affirmed and subscribed C )SS:
ounty of )
before me this_______day Sworn to or affirmed and subscribed
of , : before me this day
of ;
Deputy for Register of Wills Notary Public

My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary’s
Commission.)

NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization.

Form RW-03_ rev. 1.1.20
OATH OF NON-SUBSCRIBING WITNESS(ES)

Estate of

REGISTER OF WILLS

, Deceased

 

?

(each) being duly qualified according to law, depose(s) and say(s) that she/he/they was/were

well-acquainted with

and am/are

 

familiar with the handwriting and signature of the decedent, and that the signature of

 

Testament/Codicil of

to the foregoing instrument purporting to be the Last Will and

is in his/her own proper handwriting.

 

 

(Signature)

 

(Street Address)

 

{Signature}

 

 

(City, State, Zip)

Executed in Register’s Office

Sworn to or affirmed and subscribed
before me this___. day

of

 

 

Deputy for Register of Wills

Form RW-04_ rev. 1.1.20

(Street Address)

 

(City, State, Zip)

Executed out of Register’s Office

 

 

Commonwealth of Pennsylvania )

) SS:
County of ———_ )
Sworn to or affirmed and subscribed before
me this day of
Notary Public

My Commission Expires:

(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's
Commission.)
OATH OF WITNESS(ES) TO WILL EXECUTED BY MARK

Estate of

REGISTER OF WILLS

, Deceased

(each) a

 

(Print Name/s)

subscribing witness to the [Jwil [|Codicil(s) presented herewith, (each) being duly qualified according to
law, depose(s) and say(s) that: Testator / Testatrix was unable to sign his/her name thereto;
Testator's / Testatrix' name was subscribed thereto in Testator's / Testatrix' presence; Testator /
Testatrix made his/her mark thereon; Testator /Testatrix and deponent(s) were present when
Testator's / Testatrix' name was subscribed and when Testator / Testatrix made his/her mark; and
Testator / Testatrix was present when the undersigned signed the []will [ |Codicil as witness(es).

 

 

(Signature)

(Signature)

 

 

(Street Address)

(Street Address)

 

 

(City, State, Zip)

Executed in Register’s Office
Sworn to or affirmed and subscribed
before me this day

of ;

 

Deputy for Register of Wills

Form RW-05 rev. 1.1.20

(City, State, Zip)

Executed out of Register’s Office

Commonwealth of Pennsylvania )
) SS:
County of )

Sworn to or affirmed and subscribed before
methis...= = ss day of

 

Notary Public

My Commission Expires:

(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's
Commission.)
RENUNCIATION

REGISTER OF WILLS

Estate of , Deceased

 

The undersigned, , in the capacity/relationship as
(Name or Corporate Name) .

of the above Decedent, hereby renounces the right to

administer the Estate of the Decedent and, to the extent permitted by law pursuant to 20 Pa.C.S. §

3155, respectfully requests that Letters be issued to

 

 

 

(Date)

Name of Corporate Fiduciary (if applicable)

 

 

 

 

 

 

 

 

 

 

 

Signature of Officer/Representative Name of Person
Title of Officer/Representative Address
Address

Telephone
Telephone Email
Email

 

Signature of Person
Executed in Register’s Office g

Sworn to or affirmed and subscribed Executed out of Register’s Office
before me this day Commonwealth of Pennsylvania 5s

)SS:
of ' . County of

 

Before the undersigned personally
appeared the party executing this
renunciation and certified that he or she
executed the renunciation for the purposes

stated within on this... ss lay off

 

 

Deputy for Register of Wills Notary Public

My Commission Expires:

(Signature and Seal of Notary or other official qualified to administer

Form RW-06 rev. 01.01.20 oaths. Show date of expiration of Notary's Commission.)
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
PURSUANT TO Pa. O.C. Rule 10.5

THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY
MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE

Whether you will receive any money or property will be determined wholly or partly
by the decedent’s will. If the decedent died without a will, whether you will receive
any money or property will be determined by the intestacy laws of Pennsylvania.

BEFORE THE REGISTER OF WILLS.

INRE: ESTATE OF , Deceased

File Number
(Beneficiary)

(Address)

TO:

 

 

Please take notice of the death of the Decedent and the grant of Letters to the personal representative(s) named
below. The Decedent died on , aresident of

The Decedent died: [| testate (with a Will) or C] intestate (without a Will).

You may have a beneficial interest in the estate as follows:

(If additional space is needed, use separate sheet)
The name(s), address(es), and telephone number(s) of all personal representatives appointed are:

NAME ADDRESS TELEPHONE

 

If the Decedent died testate, the Will has been filed with the Office of the Register of Wills of
lf the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the

Register of Wills of
The Register's address is

 

and telephone number is

A copy of the Will or Petition may be obtained by contacting the Register of Wills and paying the charges for

duplication.
Date Capacity: [_] Personal Representative [" ] Counsel

Corporate Fiduciary (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

Name of Corporate Fiduciary Name of Person
Name of Representative and Title Address
Address

Telephone
Telephone Email
Email Signature of Person

 

Signature of Officer/Representative

Form RW-07 rev. 01.01.20
CERTIFICATION OF NOTICE UNDER Pa. O.C. Rule 10.5

REGISTER OF WILLS

Name of Decedent:

 

Date of Death: File Number:

 

Date Letters Granted:

 

To the Register:
| certify that Notice of Estate Administration required by Pa. O.C. Rule 10.5 of the Orphans’
Court Rules was served on or mailed to the following beneficiaries of the above-captioned

estate on ;

Name: Address:

 

 

 

 

 

 

 

(lf more space is needed, attach separate sheet.)

Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 10.5 except:

 

Date —_—___—_—________ Capacity: [ ]Personal Representative [_]counser
Corporate Fiduciary (if applicable)

 

 

 

 

 

 

 

 

 

Name of Corporate Fiduciary Name of Person
Name of Representative and Title Address
Address

Telephone
Telephone

Email
Email

 

Signature of Officer/Representative Form Signature of Person

RW-08 rev. 01.01.20
INVENTORY
REGISTER OF WILLS OF

File Number

The undersigned,

 

, Personal

 

Representative(s) of the Estate of

 

deceased, depose(s) and say(s) that the items appearing in the following Inventory include all of the personal assets
wherever situated and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said Inventory represents its fair value as of the date of Decedent's death, and that
Decedent owned no real estate outside of the Commowealth of Pennsylvania except that which appears in a memorandum

at the end of this Inventory.

| verify that the statements
made in this {Inventory are true
and correct. | understand that
false statements herein are
made subject to the penalties
of 18PaC.S. § 4904 relating
to unsworn falsification to
authorities.

Corporate Fiduciary (if applicable)

 

Name of Corporate Fiduciary

 

Name of Representative and Title

 

Signature of Officer/Representative
Attorney — (Name)

 

(Name of Law Firm)

 

Signature of Personal Representative

 

Signature of Personal Representative

 

Date
(Supreme Court [.D.#)

 

(Address)

 

(Telephone)

 

(Email)

 

 

DATE OF DEATH LAST RESIDENCE

 

DECEDENT'S SOC. SEC. NO.

 

 

 

FIGURES MUST BE TOTALED

(Attach additional sheets as needed)

 

TOTAL: $0.00

NOTE: The Memorandum of real estate outside the Commonweatth of Pennsylvania may, at the election of the personal representative, include the
value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S. § 3301(b))

Form RW-09_ rev. 01.01.20
Pa. O.C. Rule 10.6 STATUS REPORT
REGISTER OF WILLS OF

Name of Decedent:

 

Date of Death: File Number:

 

Pursuant to Pa. O.C. Rule 10.6, | report the following with respect to completion of the
administration of the above-captioned estate:

1. State whether administration of the estate is complete:............... [ ]Yes [| No

2. If the answer is No, state when the personal representative
reasonably believes that the administration will be complete:

 

3. If the answer to No. 1 is YES, state the following:
a. Did the personal representative file a final account with the Court? ....[ ]Yes [ ]No

b. The separate Orphans’ Court No. (if any) for the personal representative's account is:

 

c. Did the personal representative state an account
informally to the parties in interest? ... 20000000. 0 0. ee L] Yes C] No

d. Copies of receipts, releases, joinders, and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans’ Court or may be attached to this report.

Date Capacity: [_]Personal Representative [Counsel

Corporate Fiduciary (if applicabie)

 

 

 

 

 

 

 

 

 

 

Name of Corporate Fiduciary Name of Person
Name of Representative and Title Address
Address

Telephone
Telephone Email
Email

 

Signature of Person

 

Signature of Officer/Representative

Form RW-10_ rev. 01.01.20
