Fill - Free fillable DECEDENTS ESTATE COURT OF COMMON PLEAS OF PHANS (Beaver County Information Technology) PDF form

Page 1 of 11

Form OC-01 eff. 09.01.16

DECEDENT’S ESTATE

COURT OF COMMON PLEAS OF

OR

PHANS’ COURT DIVISION

ESTATE OF________________________________, DECEASED

No.

PETITION FOR ADJUDICATION /

STATEMENT OF PROPOSED DISTR

IBUTION

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: ________________________________________________________________________

Page 2 of 11

Estate of , Deceased

1.

Name(s) and address(es) of Petition

er(s):

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? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 Account? . . . . . . . . . . .. . . . . . . . . . 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 Adm

inistration were granted to Petitioner(s) on

Date

of Will

(if applicable):

Date(s) of

C

odicil(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

________________________________________________________________________

.

Form OC-01 eff. 09.01.16

Dates of advertising of the grant of Letters:

Petitioner: Petitioner:

_____________________________________________________________________

Page 3 of 11

Form OC-01 eff. 09.01.16

Estate of , Deceased

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 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

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.

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? .

. . . . .

. . . . . . . . . . .

. . . . . . . . . . . .

Yes

N/A

No

N/A

No

Page 4 of 11

Form OC-01 eff. 09.01.16

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 Account's 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 a

nd

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 No

tice 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 intestate 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

Page 5 of 11

Form OC-01 eff. 09.01.16

Estate of , Deceased

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).

_____________________________________________________________________

Page 6 of 11

Form OC-01 eff. 09.01.16

Estate of , Deceased

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.

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?

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.

_____________________________________________________________________

Page 7 of 11

Form OC-01 eff. 09.01.16

Estate of , Deceased

11.

Was family exemption claimed? .

......................................................

Was family exemption allowed?

.......................................................

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 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? . . . . . . . . . . . . . . . . . . .

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.

Yes

No

Yes

No

Yes

No

______________________________________________________________________

________________________________________________________________________

Form OC-01 eff. 09.01.16

Page 8 of 11

Estate of , Deceased

14. On the date of death, was the decedent a party (as a

plaintiff or defendant) in any litigation?

. . . . . . . . . . . . . . . . . . . . . . . . . .

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.

Yes

Page 9 of 11

Form OC-01 eff. 09.01.16

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? . . . . . . . . . . . . .

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 ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . .

. . . .

Yes

No

If so, attach a copy of the notice.

Yes

No

Page 10 of 11

Form OC-01 eff. 09.01.16

Estate of

, Deceased

20.

If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, i

s the

Court being asked to direct the f

iling of a Schedule of Distribution?. . . . . .

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)

Amou

nt/Proportion

Submitted By:

(

A

ll petitioners must

sign.

Place

additional

signatures

on attachment if necessary):

___________________________________________

Name

of Petitioner

Signature of Petitioner

Yes

No

Yes

No

___________________________________________

Name of Petitioner

___________________________________________

Signature of Petitioner

___________________________________________

Name of Corporate Fiduciary

___________________________________________

Name of Representative and Title

___________________________________________

Signature of Officer/Representative

Corporate Fiduciary (if applicable)

Estate of

,

Deceased

Page 11 of 11

Form OC-01 eff.

09.01.16

(Ver

ification must be by at least one petitioner.)

Verification for Individual Petitioner

The undersigned hereby verifies th

at the averment

of

f

acts 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).

Certification of Co

unsel

The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/

Statemen

t 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.

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).

Verification for Corporate Petitioner

____________________________

Date

__________________________________________

Signature of Representative for Corporate Petitioner

____________________________

Date

__________________________________________

Signature of Petitioner

___________________________

Date

__________________________________________

Signature of Counsel for Petitioner

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