Fill - Free fillable DECEDENTS ESTATE COURT OF COMMON PLEAS OF COUNTY, (County of Erie) PDF form

Form OC-01 rev. 10.13.06 Page 1 of 10

DECEDENT’S ESTATE

COURT OF COMMON PLEAS OF

COUNTY, PENNSYLVANIA

ORPHANS’ COURT DIVISION

ESTATE OF

, DECEASED

No.

PETITION FOR ADJUDICATION /

STATEMENT OF PROPOSED DISTRIBUTION

PURSUANT TO Pa. O.C. Rule 6.9

This form may be used in all cases involving the Audit of the Account of a Decedent’s Estate. If

space is insufficient, riders may be attached. Attach the spouse’s election, if any; the papers

required under items 8-19 inclusive; 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:

Reset Form

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 2 of 10

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

Name:

Address:

Identify any executors or administrators who have not joined in the Petition for

Adjudication and Statement of Proposed Distribution and state reason:

Is this the first accounting by this fiduciary?..................... Yes No

If not, identify prior accountings, the accounting periods covered, and the date of

adjudication of the prior accounting.

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:

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 3 of 10

3. Was decedent survived by a spouse? ............................. Yes No

If yes, name of the surviving spouse:

4. Has the surviving spouse filed to take an elective share? ............. Yes No

(See Section 2201 et seq. of the Probate, Estates and Fiduciaries Code)

If yes, 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

Were any children born to decedent after execution of

Will or Codicil(s)? ........................................... Yes No

If yes, give names and dates of birth:

Name: Date of Birth:

7. If required by the Medical Assistance Estate Recovery Act,

62 P.S. § 1412, was a request for a statement of claim sent to

the Department of Public Welfare? .............................. Yes No

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 4 of 10

8. Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be

given to all parties in interest 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 14 below 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

together with a statement executed by a Petitioner or counsel certifying that such

notice has been given.

C. If any person entitled to Notice is not sui juris (e.g., minors or incapacitated

persons), Notice of the Audit has been or will be given to the appropriate

representative on such party’s behalf as required by Pa. O.C. Rule 5.2.

D. If any charitable interest is involved, Notice of the Audit has been or will also be

given to the Attorney General as required under Pa. O.C. Rule 5.5. 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.

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 or

Codicil(s) or as intestate heirs if there is a complete or partial intestacy:

A. State each party’s relationship to the decedent and the nature of each party’s

interest(s):

Name and Address of Each Party in Interest Relationship and Comments, if any Interest

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 5 of 10

Name and Address of Each Party in Interest 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 for

this Audit (see

Pa. O.C. Rule 12.4).

D. 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.

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 6 of 10

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

Admitted?

Will Claim

Be Paid In

Full?

“ Yes

“ No

“ Yes

“ No

“ Yes

“ No

“ Yes

“ No

“ Yes

“ No

“ Yes

“ No

“ Yes

“ No

“ Yes

“ 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.

11. Was family exemption claimed? ................................ “ Yes “ No

Was family exemption allowed? ................................ “ Yes “ No

Family exemption claimant’s name and relationship:

Name: Relationship:

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 7 of 10

12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate

Tax paid, the date(s) of payment(s), and the interest(s) upon which paid, are as follows:

Date Payment Interest

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 of a fiduciary? ................... “ Yes “ No

If yes, provide the name of the estate, indicate whether an account has been filed and

confirmed absolutely 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.

14. 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

15. 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.

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 8 of 10

16. Had the decedent been adjudicated an incapacitated person? .......... Yes No

If yes, attach a copy of the Order if available; otherwise state the Court, term, number,

date, and name of Hearing Judge.

17. 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

18. 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

parties in interest? ........................................ Yes No

If so, attach a copy of the notice.

19. Is the Court being asked to direct

the filing of a Schedule of Distribution? .......................... Yes No

As to real estate only? ........................................ Yes No

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 9 of 10

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.

Add additional lines if necessary):

___________________________________________

Name of Petitioner:

___________________________________________

Name of Petitioner:

Enter Corporate Fiduciary (if applicable):

Estate of , Deceased

Form OC-01 rev. 10.13.06 Page 10 of 10

Verification of Petitioner

(Verification must be by at least one petitioner.)

The undersigned hereby verifies * [that he/she is title

of the above-named name of corporation and] that the 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).

____________________________________

Signature of Petitioner

* Corporate petitioners must complete bracketed information.

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.

Signature of Counsel for Petitioner

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